| NPI | 1710969480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR 1193T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA 3463) |
| Enumeration Date | 2005-11-17 |
| Last Update Date | 2007-07-08 |