| NPI | 1760579031 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MD 01248) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: WV 00327) |
| 213E00000X Podiatrist (Licence: PA SC003667L) | |
| Enumeration Date | 2006-10-06 |
| Last Update Date | 2011-02-17 |