| NPI | 1154647808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MN 909) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 213E00000X Podiatrist (Licence: WI 1018) | |
| Enumeration Date | 2010-04-20 |
| Last Update Date | 2013-08-02 |