| NPI | 1316059512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00001048TX) |
| Additional Taxonomies | 152WC0802X Optometrist Corneal and Contact Management (Licence: OR 1240ATI) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2007-07-08 |