| NPI | 1366753055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: PA SC006185) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: MO 2013028529) |
| Enumeration Date | 2010-06-28 |
| Last Update Date | 2013-08-13 |