| NPI | 1689873275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3999) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO 2604) |
| 152W00000X Optometrist (Licence: ND 666) | |
| Enumeration Date | 2007-07-13 |
| Last Update Date | 2025-05-27 |