| NPI | 1083680599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 2594) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 02169) |
| Enumeration Date | 2006-02-24 |
| Last Update Date | 2008-05-09 |