Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | OS015665 | PA |
Y | 207QS0010X | Family Doctor - Sports Medicine | 5101020228 | MI |
NPI | 1083841845 |
---|---|
Provider Name | Dr. Jason Nicholas Lazor |
First Address | Grand Rapids, MI 49503-2560 |
Second Address | Grand Rapids, MI 49546-8292 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2009 |
Last Update Date | 22/02/2021 |