| NPI | 1912008269 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA WA OD00000918) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 1020) |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2007-07-08 |