| NPI | 1023011616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: KS 12-00387) |
| Additional Taxonomies | 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: OK 113) |
| 213E00000X Podiatrist (Licence: MO 2012014963) | |
| Enumeration Date | 2005-05-27 |
| Last Update Date | 2013-04-11 |