Healthcare Provider Details

I. General information

NPI: 1104460633
Provider Name (Legal Business Name): MARGARET MASTERS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2749 BROOKLYN AVE SE
GRAND RAPIDS MI
49507-3938
US

IV. Provider business mailing address

2749 BROOKLYN AVE SE
GRAND RAPIDS MI
49507-3938
US

V. Phone/Fax

Practice location:
  • Phone: 586-337-1485
  • Fax:
Mailing address:
  • Phone: 586-337-1485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704297236
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: