| NPI | 1619611472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: MI 5951001631) |
| Enumeration Date | 2022-04-26 |
| Last Update Date | 2026-07-01 |