| NPI | 1194398602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2696) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NY 009394) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 00000) | |
| Enumeration Date | 2021-07-22 |
| Last Update Date | 2025-07-07 |