| NPI | 1922196617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: NY 278210) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101240332) |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2023-11-17 |