| NPI | 1902875610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0204X Radiology, Vascular & Interventional Radiology (Licence: VA 0101237144) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101237144) |
| Enumeration Date | 2006-03-15 |
| Last Update Date | 2021-11-04 |