| NPI | 1487764585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00001781) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 1896AT) |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2019-08-27 |