Basic Information
| Provider Information | |||||||||
| NPI: | 1730848458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIM | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21000 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811116 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 25990 CROCKER BLVD | ||||||||
| Address2: | |||||||||
| City: | HARRISON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480453450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864665466 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2021 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704286390 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.