| NPI | 1619972312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: CO 268) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: CO 00268) |
| Enumeration Date | 2005-06-17 |
| Last Update Date | 2010-07-23 |