| NPI | 1205179587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085P0229X Radiology, Pediatric Radiology (Licence: KY FL079) |
| Additional Taxonomies | 2085P0229X Radiology, Pediatric Radiology (Licence: TX 45464) |
| 2085R0202X Radiology, Diagnostic Radiology (Licence: IL 125-063799) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-04-04 |
| Last Update Date | 2025-08-20 |