| NPI | 1508979493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA WA 3806) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID 103000) |
| Enumeration Date | 2006-08-16 |
| Last Update Date | 2016-02-02 |