| NPI | 1770627945 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00003181) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA WA3181TX) |
| Enumeration Date | 2007-02-19 |
| Last Update Date | 2022-09-15 |