| NPI | 1881129120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NV 968) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 087415) |
| 152W00000X Optometrist (Licence: WI 3474) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-04-24 |
| Last Update Date | 2021-08-23 |