| NPI | 1982605473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: WI 937) |
| Additional Taxonomies | 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: MN 693) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2022-01-17 |