| NPI | 1972854222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60376580) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 3533ATI) |
| Enumeration Date | 2012-09-26 |
| Last Update Date | 2019-08-20 |