Healthcare Provider Details

I. General information

NPI: 1295313286
Provider Name (Legal Business Name): TARISAI CHRISTOPHER MAKONI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PEELER ST
KALAMAZOO MI
49008-2300
US

IV. Provider business mailing address

PO BOX 4095
KALAMAZOO MI
49003-4095
US

V. Phone/Fax

Practice location:
  • Phone: 269-345-8618
  • Fax:
Mailing address:
  • Phone: 269-345-8618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704285674
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704285674
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: