| NPI | 1225386659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP100252) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD 00003201) |
| Enumeration Date | 2012-08-15 |
| Last Update Date | 2012-08-15 |