| NPI | 1235103789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA 60385557) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG1990) |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2019-03-02 |