| NPI | 1861469900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: VA 62256) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101102522) |
| 2083X0100X Preventive Medicine, Occupational Medicine (Licence: VA 0101102522) | |
| Enumeration Date | 2006-03-08 |
| Last Update Date | 2023-08-08 |