| NPI | 1639114218 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: LA PD195R) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: SC 523) |
| 213EP1101X Podiatrist, Primary Podiatric Medicine (Licence: MS 80180) | |
| Enumeration Date | 2006-06-18 |
| Last Update Date | 2013-09-26 |