| NPI | 1619084910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00003477) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR ATI2863) |
| 152W00000X Optometrist (Licence: AK OPTT200) | |
| Enumeration Date | 2006-08-23 |
| Last Update Date | 2020-11-19 |