| NPI | 1023202140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA 60060955) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 2753ati) |
| 152W00000X Optometrist (Licence: TX 6000TG) | |
| Enumeration Date | 2007-08-31 |
| Last Update Date | 2022-03-03 |