| NPI | 1114453552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MN 1068) |
| Additional Taxonomies | 207XX0004X Orthopaedic Surgery, Foot and Ankle Surgery (Licence: ND 86) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-05-04 |
| Last Update Date | 2022-04-04 |