| NPI | 1013354133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: TX S0209) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA 255426) |
| Enumeration Date | 2013-05-30 |
| Last Update Date | 2020-02-17 |