Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 5101020051 | MI |
NPI | 1548521594 |
---|---|
Provider Name | Jesse M Guasco |
First Address | East Lansing, MI 48824-7015 |
Second Address | East Lansing, MI 48824 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2012 |
Last Update Date | 31/07/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1548521594 | (05) | MI |