Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 4901004873 | MI |
NPI | 1013319268 |
---|---|
Provider Name | Jason Andrus |
First Address | Big Rapids, MI 49307-1919 |
Second Address | Dayton, OH 45428-9000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/09/2014 |
Last Update Date | 18/09/2014 |