| NPI | 1912285479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: CA E6269) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: IA 073866) |
| 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: AZ POD001062) | |
| Enumeration Date | 2011-08-01 |
| Last Update Date | 2026-07-06 |