Healthcare Provider Details

I. General information

NPI: 1114493384
Provider Name (Legal Business Name): JEFFREY THOMAS SNYDER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 S LAPEER RD STE 102
LAKE ORION MI
48360-1468
US

IV. Provider business mailing address

2860 REGENCY DR
LAKE ORION MI
48359-1173
US

V. Phone/Fax

Practice location:
  • Phone: 248-232-0100
  • Fax:
Mailing address:
  • Phone: 734-678-8563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704257165NSA180V3
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: