| NPI | 1134246895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 224L00000X Pedorthist (Licence: IA 074625) |
| Additional Taxonomies | 246ZS0410X Specialist/Technologist, Other, Surgical Technologist |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2015-10-06 |