| NPI | 1114954013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: IA 00403) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: WI 485025) |
| Enumeration Date | 2006-06-27 |
| Last Update Date | 2017-07-28 |