| NPI | 1386997856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD 60298166) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 3475ATI) |
| 152W00000X Optometrist (Licence: ID ODP-100262) | |
| Enumeration Date | 2012-10-22 |
| Last Update Date | 2018-03-17 |