| NPI | 1689234601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP100516) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NV 1028) |
| Enumeration Date | 2019-06-20 |
| Last Update Date | 2022-05-02 |