| NPI | 1861492019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 1877) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618001359) |
| 152W00000X Optometrist (Licence: MN 2881) | |
| Enumeration Date | 2005-07-29 |
| Last Update Date | 2014-11-06 |