| NPI | 1679269948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2023020565) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 2191) |
| Enumeration Date | 2023-04-11 |
| Last Update Date | 2024-04-30 |