| NPI | 1285668426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2021-00393) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 40925) |
| 213E00000X Podiatrist (Licence: WI 612) | |
| Enumeration Date | 2006-07-11 |
| Last Update Date | 2022-06-02 |