| NPI | 1891763447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213EP1101X Podiatrist, Primary Podiatric Medicine (Licence: VA 0103000805) |
| Additional Taxonomies | 213ES0131X (Licence: VA 0103000805) |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2010-08-16 |