| NPI | 1720333792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: UT 12622351-0501) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: AZ 0810) |
| Enumeration Date | 2012-07-17 |
| Last Update Date | 2022-03-03 |