| NPI | 1265452007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001000261) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: CA PA18738) |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2019-11-19 |