| NPI | 1093078057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MN 1150) |
| Additional Taxonomies | 213ES0000X Podiatrist Sports Medicine (Licence: CA E5152) |
| 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: CA E5152) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-06-24 |
| Last Update Date | 2023-12-08 |