| NPI | 1164863734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 00003278) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA 60378496) |
| Enumeration Date | 2013-07-11 |
| Last Update Date | 2018-08-02 |