Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1013053586 |
---|---|
Provider Name | Ronald Joseph Nowak |
First Address | Warren, MI 48088-3751 |
Second Address | Warren, MI 48088-3751 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2007 |
Last Update Date | 25/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
540E00825 | BLUE CROSS BLUE SHIELD (01) | MI |