Provider Demographics
NPI:1184019135
Name:GREGORY, BRONSON
Entity Type:Individual
Prefix:
First Name:BRONSON
Middle Name:
Last Name:GREGORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35640 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1628
Mailing Address - Country:US
Mailing Address - Phone:734-729-7792
Mailing Address - Fax:
Practice Address - Street 1:35640 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1628
Practice Address - Country:US
Practice Address - Phone:734-729-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other