| NPI | 1003197971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60384269) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 7940TG) |
| Enumeration Date | 2011-09-06 |
| Last Update Date | 2014-06-06 |