| NPI | 1770997165 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 3393) |
| Enumeration Date | 2014-06-13 |
| Last Update Date | 2023-03-20 |