| NPI | 1700441102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: KY 309923) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: MN 1110) |
| Enumeration Date | 2019-05-01 |
| Last Update Date | 2026-08-28 |