Basic Information
| Provider Information | |||||||||
| NPI: | 1043897051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 LAKE LANSING RD | ||||||||
| Address2: | |||||||||
| City: | HASLETT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488408426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172859982 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5333 MCAULEY DR RM 4001 | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123980 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2021 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.