| NPI | 1902889447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: FL PO2984) |
| Additional Taxonomies | 213ES0000X Podiatrist Sports Medicine (Licence: FL PO2984) |
| 213ES0131X Podiatrist Foot Surgery (Licence: FL PO2984) | |
| Enumeration Date | 2005-11-29 |
| Last Update Date | 2010-12-01 |