| NPI | 1508838566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MO 2004001321) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2014037662) |
| 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: MO 2004001321) | |
| Enumeration Date | 2006-02-03 |
| Last Update Date | 2020-01-27 |