| NPI | 1114456225 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: CO POD.0000861) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: NM POD437) |
| 213E00000X Podiatrist (Licence: OH 36.003924) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-06-12 |
| Last Update Date | 2022-07-21 |