| NPI | 1780648055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00001020) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 1212AT) |
| Enumeration Date | 2006-04-13 |
| Last Update Date | 2017-01-27 |