| NPI | 1366561292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207NS0135X Dermatology, Procedural Dermatology (Licence: OH 35.091957) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 430184294) |
| Enumeration Date | 2007-03-29 |
| Last Update Date | 2013-09-20 |