| NPI | 1558847723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD61601217) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG003420) |
| Enumeration Date | 2018-07-11 |
| Last Update Date | 2025-04-16 |