| NPI | 1003915398 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA WA OD00001042) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR OR 1391T) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2007-07-11 |