| NPI | 1053484816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 1472) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 1308035) |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2007-07-08 |