| NPI | 1962762344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: FL PO3955) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: FL 123456) |
| Enumeration Date | 2012-05-20 |
| Last Update Date | 2018-02-09 |