| NPI | 1083055248 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60386248) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP-100281) |
| Enumeration Date | 2013-07-16 |
| Last Update Date | 2013-07-16 |