| NPI | 1487659058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: PA sc004294l) |
| Additional Taxonomies | 213EP1101X Podiatrist, Primary Podiatric Medicine (Licence: WV 331) |
| Enumeration Date | 2005-06-20 |
| Last Update Date | 2012-09-17 |