| NPI | 1417483074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: OH 57.257817) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101267461) |
| 2083A0100X Preventive Medicine, Aerospace Medicine (Licence: VA 0101267461) | |
| Enumeration Date | 2017-05-02 |
| Last Update Date | 2025-07-03 |