| NPI | 1659927788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618002751) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2019-08-14 |
| Last Update Date | 2022-10-05 |