| NPI | 1285795856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0101223026) |
| Additional Taxonomies | 2085R0202X Radiology, Diagnostic Radiology (Licence: VA 0101223026) |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2014-06-02 |