| NPI | 1275924300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: NE 29379) |
| Additional Taxonomies | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians (Licence: NE 29379) |
| 208D00000X General Practice (Licence: NE 29379) | |
| Enumeration Date | 2015-02-11 |
| Last Update Date | 2023-03-07 |