| NPI | 1982044640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: CA E5254) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX T37-2013) |
| Enumeration Date | 2013-06-26 |
| Last Update Date | 2019-10-09 |