Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 4901003774 | MI |
NPI | 1003829193 |
---|---|
Provider Name | Kristin M Sansburn |
First Address | Bay City, MI 48708-6961 |
Second Address | Bay City, MI 48708-6961 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U59102 | (02) |