Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 4301084065 | MI |
Y | 111NI0900X | Internist | 4301084065 | MI |
NPI | 1003037417 |
---|---|
Provider Name | Jeffery Allen Woo |
First Address | Grand Rapids, MI 49506-2969 |
Second Address | Grand Rapids, MI 49506-2969 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2007 |
Last Update Date | 21/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003037417 | (05) | MI |
JW1104117952 | BCBC MI (01) | MI |