| NPI | 1265421473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: KY 29591) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: KY 29591) |
| Enumeration Date | 2005-10-20 |
| Last Update Date | 2022-01-07 |