| NPI | 1427398296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: CA A132164) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA A132164) |
| 207NS0135X Dermatology, Procedural Dermatology (Licence: CA A123164) | |
| Enumeration Date | 2013-02-15 |
| Last Update Date | 2023-08-11 |