| NPI | 1336133966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: IA 362) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: NE 275) |
| 213E00000X Podiatrist (Licence: SD 99) | |
| Enumeration Date | 2005-09-09 |
| Last Update Date | 2007-11-19 |