Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 4301048819 | MI |
NPI | 1205849866 |
---|---|
Provider Name | Daryl D Wisdom |
First Address | Lowell, MI 49331-9529 |
Second Address | Lowell, MI 49331-9529 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2006 |
Last Update Date | 28/10/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B43232 | (02) | MI |