| NPI | 1255425252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: UT 7905788-1205) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: MN 55125) |
| 207N00000X Dermatology (Licence: WI 50779-020) | |
| 207N00000X Dermatology (Licence: ID 11577) | |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2024-10-10 |