| NPI | 1972506293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: CA E 4483) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MI RA002029) |
| Enumeration Date | 2005-05-31 |
| Last Update Date | 2009-05-29 |