| NPI | 1164840732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: WA MD61173707) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2085R0202X Radiology, Diagnostic Radiology (Licence: OR MD177474) | |
| Enumeration Date | 2014-04-01 |
| Last Update Date | 2025-05-10 |