| NPI | 1518588714 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085P0229X Radiology, Pediatric Radiology (Licence: PA MT233820) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 261319) |
| Enumeration Date | 2020-04-29 |
| Last Update Date | 2025-07-06 |