| NPI | 1518455187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: MO 2021019888) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2018-04-28 |
| Last Update Date | 2021-06-08 |