| NPI | 1679501399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: TN DPM0000000667) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: LA DPM200003) |
| Enumeration Date | 2006-06-29 |
| Last Update Date | 2015-04-10 |