| NPI | 1962255869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: FL ME181614) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH vf197052) |
| Enumeration Date | 2024-04-09 |
| Last Update Date | 2026-07-04 |