| NPI | 1700990736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 202K00000X (Licence: TX G1239) |
| Additional Taxonomies | 207NS0135X Dermatology, Procedural Dermatology (Licence: TX G1239) |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2007-07-16 |