| NPI | 1164496030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: AZ 3179) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 3179) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 3179) | |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2019-01-22 |