| NPI | 1215333943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9108370) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: FL PA9108370) |
| Enumeration Date | 2014-11-06 |
| Last Update Date | 2025-01-23 |