| NPI | 1679586168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR OR 1450T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA WA OD 00001253) |
| Enumeration Date | 2006-08-14 |
| Last Update Date | 2007-07-08 |