| NPI | 1003923012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 1839) |
| Additional Taxonomies | 152WC0802X Optometrist Corneal and Contact Management (Licence: MN 1839) |
| Enumeration Date | 2006-08-24 |
| Last Update Date | 2011-12-16 |