| NPI | 1417154683 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: UT 97811501205) |
| Additional Taxonomies | 2085B0100X Radiology Body Imaging (Licence: CA A127379) |
| 208D00000X General Practice (Licence: WI 52979-20) | |
| Enumeration Date | 2007-06-29 |
| Last Update Date | 2021-10-21 |