| NPI | 1194216598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3551) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 3500-35) |
| Enumeration Date | 2018-05-22 |
| Last Update Date | 2024-05-08 |