| NPI | 1396585923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 4024) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 390200000X) |
| 152W00000X Optometrist (Licence: CO OPT.0004048) | |
| Enumeration Date | 2024-05-30 |
| Last Update Date | 2025-08-25 |