| NPI | 1841290624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MO 000576) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: KS 12-00278) |
| Enumeration Date | 2005-07-22 |
| Last Update Date | 2007-07-08 |