Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 4704211628 | MI |
NPI | 1003859596 |
---|---|
Provider Name | Mary Barr |
First Address | Grand Rapids, MI 49503-2560 |
Second Address | Grand Rapids, MI 49546-8292 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2006 |
Last Update Date | 15/08/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q64556 | (02) |