Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | 3405-35 | WI |
Y | 152W00000X | Optometrist | 3461 | MN |
NPI | 1003254590 |
---|---|
Provider Name | Lauren Jordan |
First Address | Andover, MN 55304-3669 |
Second Address | North Oaks, MN 55127-7088 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2013 |
Last Update Date | 25/09/2018 |