| NPI | 1053060509 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: CO 0000967) | 
| Additional Taxonomies | 213EP1101X Podiatrist, Primary Podiatric Medicine (Licence: CO 0000967) | 
| Enumeration Date | 2022-03-22 | 
| Last Update Date | 2025-07-03 |