| NPI | 1386648616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: FL ME146752) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: FL BK3751460) |
| 207NS0135X Dermatology, Procedural Dermatology (Licence: NY 178676-1) | |
| 207NS0135X Dermatology, Procedural Dermatology (Licence: FL ME146752) | |
| Enumeration Date | 2005-06-01 |
| Last Update Date | 2021-07-16 |