| NPI | 1649894569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: UT 13244494-0501) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MI 5951001364) |
| Enumeration Date | 2020-06-06 |
| Last Update Date | 2023-04-05 |