| NPI | 1215190897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD 60022209) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 3275ATI) |
| Enumeration Date | 2008-07-03 |
| Last Update Date | 2009-06-23 |