| NPI | 1124883012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD61568824) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA 35753) |
| Enumeration Date | 2024-02-19 |
| Last Update Date | 2025-08-24 |