| NPI | 1831571157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: VA 0101275773) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2015-06-23 |
| Last Update Date | 2025-05-13 |