| NPI | 1497019087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: WY 153) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: PA SC006362) |
| Enumeration Date | 2012-06-27 |
| Last Update Date | 2015-07-13 |