| NPI | 1962767483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60724031) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: HI 759) |
| Enumeration Date | 2012-07-10 |
| Last Update Date | 2018-05-16 |