| NPI | 1619072105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MI 5901002606) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: GA 000903) |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2015-08-24 |