| NPI | 1689069312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: UT 12603519-1205) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: TX S1396) |
| 207ND0101X Dermatology, MOHS-Micrographic Surgery (Licence: UT 12603519-1205) | |
| Enumeration Date | 2015-03-31 |
| Last Update Date | 2022-09-27 |