| NPI | 1659620672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: AZ 5259) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 5259) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 5259) | |
| Enumeration Date | 2012-09-05 |
| Last Update Date | 2019-03-11 |