| NPI | 1760495980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: OR MD17781) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: WA MD00033534) |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2007-07-10 |