| NPI | 1295778124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG000992) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: DE I3-0001415) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2021-09-20 |