| NPI | 1205276474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 003752) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: CT 003752) |
| Enumeration Date | 2013-07-02 |
| Last Update Date | 2023-10-10 |