| NPI | 1780656611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: FL OS14034) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: FL UO3599) |
| 363A00000X Physician Assistant (Licence: FL PA9102818) | |
| Enumeration Date | 2006-02-04 |
| Last Update Date | 2019-08-26 |