| NPI | 1114901733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 2353) |
| Additional Taxonomies | 207W00000X Ophthalmology (Licence: MN 2353) |
| Enumeration Date | 2005-12-06 |
| Last Update Date | 2022-07-21 |