Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 4301060023 | MI |
NPI | 1073537403 |
---|---|
Provider Name | Tod Wyn |
First Address | Holland, MI 49423-3719 |
Second Address | Holland, MI 49423-3719 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2006 |
Last Update Date | 19/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
930017975 | RAILROAD MEDICARE (01) | MI |
F95729 | (02) | MI |
TW060023 | BCBS (01) | MI |