| NPI | 1821253386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: IA 000811) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MO 2011028644) |
| Enumeration Date | 2008-07-24 |
| Last Update Date | 2014-03-12 |