| NPI | 1720108012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: FL PO3942) |
| Additional Taxonomies | 213ES0000X Podiatrist Sports Medicine (Licence: FL PO3294) |
| Enumeration Date | 2007-03-30 |
| Last Update Date | 2011-03-01 |