| NPI | 1336453091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: AZ 0730) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: AZ 0730) |
| Enumeration Date | 2010-08-04 |
| Last Update Date | 2012-02-17 |