| NPI | 1619215738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084N0400X Psychiatry & Neurology, Neurology (Licence: FL 9112051) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: FL 9112051) |
| 363A00000X Physician Assistant (Licence: UT 2853911206) | |
| Enumeration Date | 2013-01-24 |
| Last Update Date | 2021-12-15 |