| NPI | 1407378011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: SC 3658) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3658) |
| Enumeration Date | 2017-07-14 |
| Last Update Date | 2025-10-14 |