| NPI | 1023096989 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: CO 339) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MO 448) |
| 213E00000X Podiatrist (Licence: WY 116) | |
| Enumeration Date | 2006-01-02 |
| Last Update Date | 2010-07-22 |