| NPI | 1497801633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA 1642) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 1758ATI) |
| 152W00000X Optometrist (Licence: WY 169) | |
| Enumeration Date | 2007-01-27 |
| Last Update Date | 2007-07-09 |