| NPI | 1356334734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA 60589963) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 2307-AT) |
| Enumeration Date | 2005-08-31 |
| Last Update Date | 2023-03-05 |