| NPI | 1972665586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR 2978T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA 3956) |
| Enumeration Date | 2006-12-14 |
| Last Update Date | 2007-07-08 |