| NPI | 1265774335 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: MN 58046) |
| Additional Taxonomies | 208D00000X General Practice (Licence: FL ME 121477) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MN 58046) | |
| Enumeration Date | 2013-03-26 |
| Last Update Date | 2019-11-25 |