Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | LN001085 | MI |
N | 222Z00000X | Podiatrist | LN001085 | MI |
N | 213ES0131X | Foot Surgery | LN001085 | MI |
NPI | 1245239631 |
---|---|
Provider Name | Mr. Larry R Nishon |
First Address | Okemos, MI 48864-3986 |
Second Address | Okemos, MI 48864-3986 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1710897 | (05) | MI |
2700008 | PHP (01) | MI |
4814430001 | DMERC (01) | MI |
4814430002 | DMERC (01) | MI |
T34330 | (02) | MI |