| NPI | 1124023213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN LD1918000) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 1407-035) |
| Enumeration Date | 2005-06-16 |
| Last Update Date | 2022-07-21 |