| NPI | 1255699781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0132000005) |
| Additional Taxonomies | 2471C3402X Radiologic Technologist, Radiography (Licence: VA 0120004083) |
| Enumeration Date | 2012-05-03 |
| Last Update Date | 2012-05-03 |