Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1073029393 |
---|---|
Provider Name | Mr. Jacob Bustamante |
First Address | Bingham Farms, MI 48025-2454 |
Second Address | Bingham Farms, MI 48025-2454 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2017 |
Last Update Date | 21/12/2017 |