MEDICARE: DENISE DYAR NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704164070	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11712516	OTHER		CAQH

General Provider Information

NPI Number	:	1487632923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE DYAR NP

Provider Business Mailing Address
First Line	:	38935 ANN ARBOR RD
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48150-3354
Country	:	US
Telephone Number	:	734-632-0175
Fax Number	:	734-632-0182

Provider Business Practice Location Address
First Line	:	15855 19 MILE RD
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48038-3504
Country	:	US
Telephone Number	:	586-236-2601
Fax Number	:	586-263-2589

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	09/04/2007

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