Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 5101012764 | MI |
NPI | 1003874587 |
---|---|
Provider Name | Susan Marie Lessner-Boesler |
First Address | Canton, MI 48187-5908 |
Second Address | Jackson, MI 49201-1753 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G58783 | (02) | MI |