| NPI | 1952800336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: TX S3067) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 2085P0229X Radiology, Pediatric Radiology (Licence: MA 1014360) | |
| Enumeration Date | 2018-02-12 |
| Last Update Date | 2024-08-20 |