| NPI | 1083035372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: VA 0101258777) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101258777) |
| Enumeration Date | 2014-01-03 |
| Last Update Date | 2026-07-29 |