| NPI | 1275189334 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MI 5601009409) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: MI 5601009409) |
| Enumeration Date | 2019-08-14 |
| Last Update Date | 2025-01-14 |