Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207YS0123X | Facial Plastic Surgeon | 02004173A | IN |
Y | 207YS0123X | Facial Plastic Surgeon | 5101022863 | MI |
N | 208200000X | Surgeon | 5101022863 | MI |
N | 208600000X | Surgeon | 5101022863 | MI |
NPI | 1578768644 |
---|---|
Provider Name | Jason Trygve Stubbs |
First Address | Holland, MI 49424 |
Second Address | Holland, MI 49424 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2007 |
Last Update Date | 14/08/2018 |