| NPI | 1790533172 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901005866) | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program | 
| Enumeration Date | 2024-05-09 | 
| Last Update Date | 2025-05-01 |