| NPI | 1811990021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: TX 3075) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: KS 12-00325) |
| Enumeration Date | 2005-05-23 |
| Last Update Date | 2021-08-10 |