| NPI | 1285624601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP100067) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD00003976) |
| Enumeration Date | 2005-10-26 |
| Last Update Date | 2023-08-23 |