| NPI | 1255569273 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: OR DO157838) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 5101018458) |
| Enumeration Date | 2009-06-29 |
| Last Update Date | 2013-05-08 |