Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1104492172 |
---|---|
Provider Name | Michael Ericson Perez |
First Address | Las Vegas, NV 89121-5067 |
Second Address | Las Vegas, NV 89121-5067 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2021 |
Last Update Date | 01/06/2021 |