| NPI | 1063689776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085N0700X Radiology Neuroradiology (Licence: NC 2010-00981) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 128001) |
| Enumeration Date | 2008-05-12 |
| Last Update Date | 2012-03-01 |