Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LF0000X | Nurse Practitioner - Family Medicine | 4704261932 | MI |
Y | 363LP2300X | Nurse Practitioner - Primary Care | 4704261932 | MI |
NPI | 1043601164 |
---|---|
Provider Name | Li Song |
First Address | Rochester, MI 48306-4756 |
Second Address | Warren, MI 48092-4230 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/02/2015 |
Last Update Date | 25/03/2015 |