| NPI | 1245515394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60483702) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD60483702OPT-OP) |
| 152W00000X Optometrist (Licence: MT OPT-OPT-LIC-3679) | |
| Enumeration Date | 2011-10-19 |
| Last Update Date | 2020-12-07 |