| NPI | 1265924724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MI 5901400398) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: TX T36-2018) |
| Enumeration Date | 2018-05-31 |
| Last Update Date | 2024-03-06 |