| NPI | 1700309556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG003454) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KY 2084DT) |
| Enumeration Date | 2017-07-24 |
| Last Update Date | 2019-02-18 |