| NPI | 1689780132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: CT 000768) |
| Additional Taxonomies | 335E00000X Prosthetic/Orthotic Supplier (Licence: CT 000768) |
| Enumeration Date | 2006-08-21 |
| Last Update Date | 2020-10-23 |