| NPI | 1669463519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213EP1101X Podiatrist, Primary Podiatric Medicine (Licence: WA 0196005) |
| Additional Taxonomies | 213ES0000X Podiatrist, Sports Medicine (Licence: WA 0196005) |
| 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: WA 0196005) | |
| Enumeration Date | 2005-10-31 |
| Last Update Date | 2007-07-08 |