| NPI | 1700349719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MN 1108) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: WI 1190) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-08 |
| Last Update Date | 2022-10-21 |