| NPI | 1396721544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: CO 648) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: UT 3476040501) |
| Enumeration Date | 2005-12-20 |
| Last Update Date | 2008-02-19 |