Provider Demographics
NPI:1588018006
Name:STETSON, DAVID (RN)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:STETSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 CASS ST
Mailing Address - Street 2:SUITE 2A & 2D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2589
Mailing Address - Country:US
Mailing Address - Phone:231-922-4810
Mailing Address - Fax:231-943-2590
Practice Address - Street 1:940 E 8TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2893
Practice Address - Country:US
Practice Address - Phone:231-922-4810
Practice Address - Fax:231-929-0416
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704274675163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1184087272Medicaid
MI1629431713Medicaid