| NPI | 1265841266 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG002990) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AL R241TAA13) |
| Enumeration Date | 2014-08-05 |
| Last Update Date | 2022-01-24 |