| NPI | 1669691572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS 11446) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: FL PO3287) |
| Enumeration Date | 2007-04-25 |
| Last Update Date | 2016-07-19 |