| NPI | 1104188077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: PA MD463556) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116024813) |
| Enumeration Date | 2012-06-15 |
| Last Update Date | 2018-04-25 |