| NPI | 1114689155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 224L00000X Pedorthist (Licence: VA CPED4184) |
| Additional Taxonomies | 225000000X Orthotic Fitter |
| 225000000X Orthotic Fitter (Licence: VA CFO04357) | |
| Enumeration Date | 2021-10-07 |
| Last Update Date | 2022-03-10 |