| NPI | 1285636449 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0131X (Licence: CO 540) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: CO 540) |
| 213E00000X Podiatrist (Licence: UT 3406870501) | |
| Enumeration Date | 2005-06-01 |
| Last Update Date | 2019-08-19 |