| NPI | 1679869119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: CA 20A17149) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NE 942) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-06-23 |
| Last Update Date | 2023-12-26 |