Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 4704307160 | MI |
NPI | 1114684198 |
---|---|
Provider Name | Samantha Green |
First Address | Warren, MI 48093-3472 |
Second Address | Warren, MI 48093-3472 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/11/2021 |
Last Update Date | 19/01/2022 |