| NPI | 1922686872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MO 2024017959) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: MO 2024017959) |
| Enumeration Date | 2021-03-31 |
| Last Update Date | 2024-07-26 |