| NPI | 1710063169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213EP1101X Podiatrist, Primary Podiatric Medicine (Licence: KY 00140) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: KY 00140) |
| Enumeration Date | 2006-10-28 |
| Last Update Date | 2017-02-25 |