| NPI | 1063833838 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085P0229X Radiology Pediatric Radiology (Licence: NC 2018-01571) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2013-12-22 |
| Last Update Date | 2019-07-15 |