| NPI | 1407813082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: FL PO3178) |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site (Licence: FL BR9647201) |
| Enumeration Date | 2006-04-27 |
| Last Update Date | 2014-10-22 |