| NPI | 1578551412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: MO 2022033251) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363AM0700X Physician Assistant Medical (Licence: OK 1051) | |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2025-05-06 |