| NPI | 1679766844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0204X Radiology, Vascular & Interventional Radiology (Licence: TX S5501) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 22100) |
| 2085R0204X Radiology, Vascular & Interventional Radiology (Licence: WA MD00038452) | |
| Enumeration Date | 2007-08-21 |
| Last Update Date | 2021-12-29 |