Provider Demographics
NPI:1437551595
Name:MUZIRMAN, PRIMA MARDHATILLAH (NP)
Entity Type:Individual
Prefix:MISS
First Name:PRIMA
Middle Name:MARDHATILLAH
Last Name:MUZIRMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6346 BEECHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-5735
Mailing Address - Country:US
Mailing Address - Phone:517-410-1388
Mailing Address - Fax:
Practice Address - Street 1:1780 E PARNALL RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-7136
Practice Address - Country:US
Practice Address - Phone:517-780-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704248754363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily