| NPI | 1154334696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: WV 00357) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: KY 00295) |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2021-11-17 |