Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 20A10296 | CA |
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 5101016107 | MI |
NPI | 1063690535 |
---|---|
Provider Name | Clarence L Nicodemus |
First Address | East Lansing, MI 48824-7015 |
Second Address | East Lansing, MI 48823-5376 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2008 |
Last Update Date | 07/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1063690535 | (05) | MI |