Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 4704237964 | MI |
NPI | 1073267753 |
---|---|
Provider Name | Roland H Gaines JR. |
First Address | Redford, MI 48239-2995 |
Second Address | Redford, MI 48239-2995 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/02/2022 |
Last Update Date | 10/02/2022 |