| NPI | 1275873952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WY 349T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO OPT0003031) |
| Enumeration Date | 2013-02-18 |
| Last Update Date | 2014-03-18 |