| NPI | 1134241920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 2411) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 2512035) |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2021-03-10 |