| NPI | 1619983590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: CA G32804) |
| Additional Taxonomies | 261QR0208X Clinic/Center, Radiology, Mobile (Licence: CA G302804) |
| 293D00000X Physiological Laboratory (Licence: CA G32804) | |
| Enumeration Date | 2006-07-31 |
| Last Update Date | 2014-02-11 |