| NPI | 1023764040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100530) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: ID ODP-100530) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: ID 100530) | |
| Enumeration Date | 2022-02-28 |
| Last Update Date | 2022-02-28 |