| NPI | 1831253327 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 2746) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 02338) |
| 152W00000X Optometrist (Licence: WI 2755-035) | |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2020-12-22 |