Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0100X | Health Service | S326585744610 | MI |
NPI | 1366893869 |
---|---|
Provider Name | Marissa Stager |
First Address | Port Huron, MI 48060-4224 |
Second Address | Port Huron, MI 48060-8127 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2016 |
Last Update Date | 26/06/2016 |