| NPI | 1104351956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: FL PO4164) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MI 5901400350) |
| Enumeration Date | 2017-04-28 |
| Last Update Date | 2020-11-06 |