| NPI | 1356627335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 243U00000X Radiology Practitioner Assistant |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 173000000X Legal Medicine | |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2011-10-23 |
| Last Update Date | 2023-11-29 |