| NPI | 1508942319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: KY 42935) |
| Additional Taxonomies | 2085P0229X Radiology Pediatric Radiology (Licence: KY 42935) |
| 2085P0229X Radiology Pediatric Radiology (Licence: TN 50372) | |
| Enumeration Date | 2006-10-27 |
| Last Update Date | 2018-10-04 |