| NPI | 1871055111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: VA 0102206223) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 2085P0229X Radiology, Pediatric Radiology (Licence: DC MTL500002541) | |
| Enumeration Date | 2019-04-04 |
| Last Update Date | 2024-06-26 |