| NPI | 1790207496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: TN 0442) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2017-07-13 |
| Last Update Date | 2020-09-08 |