Healthcare Provider Details

I. General information

NPI: 1043900707
Provider Name (Legal Business Name): AJAY EAPEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W FAIR AVE STE 36
MARQUETTE MI
49855-2675
US

IV. Provider business mailing address

1414 W FAIR AVE STE 36
MARQUETTE MI
49855-2675
US

V. Phone/Fax

Practice location:
  • Phone: 906-449-1010
  • Fax:
Mailing address:
  • Phone: 906-449-1010
  • 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: