| NPI | 1679955041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: MI 5101022765) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116028208) |
| Enumeration Date | 2015-06-22 |
| Last Update Date | 2018-11-18 |