Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 4301500673 | MI |
N | 207QS0010X | Family Doctor - Sports Medicine | 4301500673 | MI |
NPI | 1326427105 |
---|---|
Provider Name | Paolo Nino Balmaseda |
First Address | Novi, MI 48374-1212 |
Second Address | Novi, MI 48374-1212 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2015 |
Last Update Date | 29/07/2019 |