| NPI | 1457551467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3708) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 007160) |
| Enumeration Date | 2007-07-19 |
| Last Update Date | 2021-05-04 |