| NPI | 1356446900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR 1605T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD00001501) |
| Enumeration Date | 2006-09-14 |
| Last Update Date | 2007-07-12 |