| NPI | 1770079659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: OR DP211294) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: TX T58-2019) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-07-03 |
| Last Update Date | 2022-05-19 |