| NPI | 1184623290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: KY 00193) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: KY 00193) |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| Enumeration Date | 2005-07-20 |
| Last Update Date | 2019-04-02 |