| NPI | 1609885128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MT 128) |
| Additional Taxonomies | 335E00000X Prosthetic/Orthotic Supplier (Licence: MT 128) |
| Enumeration Date | 2006-08-05 |
| Last Update Date | 2015-09-15 |