| NPI | 1568985992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: NY 316402) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 33233) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 316402) | |
| Enumeration Date | 2017-07-18 |
| Last Update Date | 2023-07-17 |