| NPI | 1093256539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NE 1478) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 152W00000X Optometrist (Licence: WI 3479) | |
| Enumeration Date | 2017-03-16 |
| Last Update Date | 2019-03-11 |