| NPI | 1033598172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60573767) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NV 879) |
| Enumeration Date | 2015-05-21 |
| Last Update Date | 2020-03-13 |