| NPI | 1578551412 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: MO 2022033251) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OK 1051) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2025-01-03 |