| NPI | 1174961916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: FL ME 128153) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL TRN20603) |
| 363AM0700X Physician Assistant Medical (Licence: FL TRN20603) | |
| Enumeration Date | 2013-06-13 |
| Last Update Date | 2016-05-04 |