| NPI | 1194245043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO OPT.0003608) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD60767319) |
| Enumeration Date | 2017-06-21 |
| Last Update Date | 2022-04-01 |