Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1194375436 |
---|---|
Provider Name | Lucas Wayne Conner |
First Address | Bingham Farms, MI 48025-2452 |
Second Address | Bingham Farms, MI 48025-2452 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/09/2019 |
Last Update Date | 18/09/2019 |