| NPI | 1285650952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: MN 65880) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101239993) |
| Enumeration Date | 2006-07-14 |
| Last Update Date | 2021-07-19 |