| NPI | 1326119223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN LD1652000) |
| Additional Taxonomies | 152WC0802X Optometrist Corneal and Contact Management (Licence: MN LD1652000) |
| 152WX0102X Optometrist Occupational Vision (Licence: MN LD1652000) | |
| 152WX0102X Optometrist Occupational Vision (Licence: ND 362) | |
| Enumeration Date | 2006-11-13 |
| Last Update Date | 2013-12-27 |