| NPI | 1396973376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: MI 5101018335) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL OS12448) |
| Enumeration Date | 2009-06-29 |
| Last Update Date | 2016-02-03 |