| NPI | 1215040233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00001198) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 1372T) |
| Enumeration Date | 2006-08-16 |
| Last Update Date | 2007-07-11 |