| NPI | 1770287716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 261QP1100X Clinic/Center, Podiatric |
| Enumeration Date | 2023-03-27 |
| Last Update Date | 2025-12-12 |