| NPI | 1366574196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213EP1101X Podiatrist, Primary Podiatric Medicine (Licence: WA P000000821) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004866) |
| Enumeration Date | 2007-03-09 |
| Last Update Date | 2013-12-10 |