| NPI | 1124882014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG004234) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA OPT35927TLG) |
| Enumeration Date | 2024-02-12 |
| Last Update Date | 2025-03-24 |