| NPI | 1962519124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: TN DPM000510) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: NC 391) |
| Enumeration Date | 2006-08-24 |
| Last Update Date | 2014-04-01 |