Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2301006134 | MI |
NPI | 1295763019 |
---|---|
Provider Name | Christopher A Moran |
First Address | Traverse City, MI 49684-9153 |
Second Address | Traverse City, MI 49684-9153 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2006 |
Last Update Date | 08/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
OE910270 | BLUE CROSS/BLUE CARE NUMB (01) | MI |