| NPI | 1790115004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 222Z00000X Orthotist (Licence: WA 01 60414623) |
| Additional Taxonomies | 224P00000X Prosthetist (Licence: WA PS 60414610) |
| Enumeration Date | 2013-11-22 |
| Last Update Date | 2013-11-22 |