| NPI | 1740574698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0204X Radiology, Vascular & Interventional Radiology (Licence: VA 0101252368) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101252368) |
| 2085R0202X Radiology, Diagnostic Radiology (Licence: VA 0101252368) | |
| Enumeration Date | 2011-06-07 |
| Last Update Date | 2023-10-18 |