| NPI | 1902819543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MO 000753) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: KS 12-00290) |
| Enumeration Date | 2006-08-14 |
| Last Update Date | 2007-07-08 |