| NPI | 1417307679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: WA PO61317396) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: MI 5901002799) |
| Enumeration Date | 2016-06-20 |
| Last Update Date | 2025-07-29 |