Healthcare Provider Details

I. General information

NPI: 1265976971
Provider Name (Legal Business Name): DEGARA APP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W GREENLAWN AVE
LANSING MI
48910
US

IV. Provider business mailing address

PO BOX 4458 DEPT # 206
HOUSTON TX
77210-4458
US

V. Phone/Fax

Practice location:
  • Phone: 517-975-6000
  • Fax: 904-559-4370
Mailing address:
  • Phone: 855-246-8607
  • Fax: 629-216-0568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES GRIMES
Title or Position: CFO
Credential:
Phone: 615-551-6611