| NPI | 1902233208 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: NM MD2025-0431) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ 9388) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM RS2022-0786) | |
| Enumeration Date | 2013-10-01 |
| Last Update Date | 2025-06-11 |