Individual
NHI LE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
8550 MARSHALL DR STE 120, LENEXA, KS 66214-9836
(913) 677-3600
Mailing address
PO BOX 825159, PHILADELPHIA, PA 19182-5159
(866) 626-1540
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
12-00499
KS
213E00000X
Podiatrist
Primary
2024027136
MO
213ES0103X
Foot & Ankle Surgery Podiatrist
2024027136
MO
213ES0131X
Foot Surgery Podiatrist
12-00499
KS
Other
Enumeration date
03/23/2021
Last updated
04/30/2025
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