| NPI | 1972009439 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: WV 2711) |
| Additional Taxonomies | 213ES0000X Podiatrist, Sports Medicine (Licence: WV 2711) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-03 |
| Last Update Date | 2021-08-23 |