| NPI | 1902420813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: VA 0103301386) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MI 5951001391) |
| Enumeration Date | 2020-06-05 |
| Last Update Date | 2023-06-13 |