| NPI | 1962551127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MI 59010007841) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MI MW000841) |
| Enumeration Date | 2007-01-09 |
| Last Update Date | 2026-03-19 |