| NPI | 1912104811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG001912) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VT 030-0000345) |
| Enumeration Date | 2007-07-03 |
| Last Update Date | 2020-01-22 |