| NPI | 1174864904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AK 116944) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG002808) |
| Enumeration Date | 2013-03-04 |
| Last Update Date | 2018-07-03 |