| NPI | 1912591884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD61217146) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH OPT.006923) |
| Enumeration Date | 2021-02-22 |
| Last Update Date | 2022-03-05 |