| NPI | 1144229394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00003839) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR AT2798) |
| 152W00000X Optometrist (Licence: AK OPTT308) | |
| Enumeration Date | 2005-07-19 |
| Last Update Date | 2020-12-07 |