Healthcare Provider Details

I. General information

NPI: 1558065383
Provider Name (Legal Business Name): AGUSTIN PEREZ RODRIGUEZ NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W GIER ST
LANSING MI
48906-2940
US

IV. Provider business mailing address

113 W GIER ST
LANSING MI
48906-2940
US

V. Phone/Fax

Practice location:
  • Phone: 517-894-3357
  • Fax:
Mailing address:
  • Phone: 517-894-3357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704319370
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: