| NPI | 1720022452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: GA POD000558) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: SC 96) |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2019-02-06 |