Healthcare Provider Details

I. General information

NPI: 1952058125
Provider Name (Legal Business Name): MR. CONNOR KENNETH GWINN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2509
US

IV. Provider business mailing address

225 HASTINGS ST NE APT 309
GRAND RAPIDS MI
49503-1526
US

V. Phone/Fax

Practice location:
  • Phone: 616-233-1678
  • Fax:
Mailing address:
  • Phone: 586-907-1316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: