| NPI | 1164411930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 2496) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AK 358) |
| Enumeration Date | 2005-10-14 |
| Last Update Date | 2016-11-29 |