| NPI | 1962453159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MT 47167) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MT 47167) |
| 2085R0202X Radiology, Diagnostic Radiology (Licence: OR 26978) | |
| 2085R0204X Radiology, Vascular & Interventional Radiology (Licence: WA MD46039) | |
| Enumeration Date | 2006-05-13 |
| Last Update Date | 2021-01-11 |