| NPI | 1538154612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: CA GFE42087) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: FL ME133817) |
| Enumeration Date | 2005-09-15 |
| Last Update Date | 2018-03-17 |