| NPI | 1225664675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: VA 0101272997) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2020-03-18 |
| Last Update Date | 2024-08-22 |