| NPI | 1093155541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: MA 273596) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: MA 256996) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: CO TL0005039) | |
| Enumeration Date | 2013-06-28 |
| Last Update Date | 2018-03-19 |