Provider Demographics
NPI:1598476061
Name:KONAN, EDISON
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:
Last Name:KONAN
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 1:15450 HEATHERWOOD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-8523
Mailing Address - Country:US
Mailing Address - Phone:734-720-2097
Mailing Address - Fax:
Practice Address - Street 1:15450 HEATHERWOOD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-8523
Practice Address - Country:US
Practice Address - Phone:734-720-2097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 106S00000X, 172A00000X, 372600000X
MI7501016017225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172A00000XOther Service ProvidersDriver
No372600000XNursing Service Related ProvidersAdult Companion