| NPI | 1619064896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: LA 1418-542T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG-001681) |
| Enumeration Date | 2006-10-06 |
| Last Update Date | 2014-07-07 |