| NPI | 1790210664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: VA 0103301161) |
| Additional Taxonomies | 213ES0131X Podiatrist, Foot Surgery (Licence: VA 0103301161) |
| Enumeration Date | 2017-04-27 |
| Last Update Date | 2019-01-04 |