Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 5151014128 | MI |
NPI | 1013579754 |
---|---|
Provider Name | Tyler Mumm |
First Address | Garden City, MI 48135-4001 |
Second Address | Garden City, MI 48135-4001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2019 |
Last Update Date | 02/07/2019 |