Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NI0013X | Independent Medical Examiner | 3090 | CO |
NPI | 1114287489 |
---|---|
Provider Name | Dr. Michael D Tennant |
First Address | Nucla, CO 81424-0454 |
Second Address | Nucla, CO 81424-0454 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/05/2012 |
Last Update Date | 07/09/2012 |