| NPI | 1063479467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: PA SC001495L) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: NJ 25MD00121000) |
| Enumeration Date | 2006-04-28 |
| Last Update Date | 2007-10-29 |