| NPI | 1902951486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: OR DP002200) |
| Additional Taxonomies | 213EP1101X Podiatrist Primary Podiatric Medicine (Licence: OR DP002200) |
| 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: OR DP002200) | |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2007-07-08 |