| NPI | 1255900874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ OPT-002757) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 3736) |
| Enumeration Date | 2021-06-18 |
| Last Update Date | 2023-12-13 |