Healthcare Provider Details

I. General information

NPI: 1740683069
Provider Name (Legal Business Name): MOISES FAJARDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MOISES ROMEO FAJARDO

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 W 14 MILE RD
CLAWSON MI
48017-1499
US

IV. Provider business mailing address

2445 CLAYMONT DR
TROY MI
48098-2493
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 248-792-7114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704267838
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704267838
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: