| NPI | 1932767753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP100472) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD60970822) |
| Enumeration Date | 2019-06-05 |
| Last Update Date | 2019-08-08 |