| NPI | 1043259419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR 2363ATI) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA 2000Tx) |
| Enumeration Date | 2006-06-04 |
| Last Update Date | 2007-07-08 |