| NPI | 1477048585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG003853) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 9539T) |
| Enumeration Date | 2018-06-30 |
| Last Update Date | 2021-12-17 |