Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 4301116993 | MI |
Y | 207QS0010X | Family Doctor - Sports Medicine | 4301116993 | MI |
NPI | 1225483621 |
---|---|
Provider Name | Ryan Mark |
First Address | Apo, AP 96367-0037 |
Second Address | Apo, AP 96368 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2016 |
Last Update Date | 23/09/2020 |