| NPI | 1992902662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: VA 0102206282) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: WA OP70075807) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2007-06-27 |
| Last Update Date | 2026-07-13 |