| NPI | 1386038917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0204X Radiology, Vascular & Interventional Radiology (Licence: SD 24204) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208600000X Surgery (Licence: WA ML61070568) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2015-03-20 |
| Last Update Date | 2026-07-27 |