| NPI | 1124178355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: AR 174) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MO 000805) |
| 213E00000X Podiatrist (Licence: WI 768) | |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2007-07-08 |