| NPI | 1619460086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: SC 52642) |
| Additional Taxonomies | 208600000X Surgery (Licence: SC LL52642) |
| Enumeration Date | 2018-06-11 |
| Last Update Date | 2025-08-14 |