| NPI | 1255318929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA 60612986) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 2900-035) |
| Enumeration Date | 2005-12-23 |
| Last Update Date | 2017-09-18 |