| NPI | 1275647000 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR 3169ATI) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD.OD.701323) |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2026-09-02 |