| NPI | 1508050337 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60119604) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR ATI3220) |
| 152W00000X Optometrist (Licence: ID ODP-100229) | |
| 152W00000X Optometrist (Licence: OR 3220 ATI) | |
| Enumeration Date | 2007-09-05 |
| Last Update Date | 2020-11-13 |