| NPI | 1053691808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 254326) |
| Additional Taxonomies | 2085N0700X Radiology Neuroradiology (Licence: NY 254326) |
| 2085R0202X Radiology Diagnostic Radiology (Licence: NY 254326) | |
| Enumeration Date | 2011-08-25 |
| Last Update Date | 2011-08-25 |