Provider Demographics
NPI:1124894050
Name:SECRETO, JOSEPH D (AGNP)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:D
Last Name:SECRETO
Suffix:
Gender:M
Credentials:AGNP
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Other - Credentials:
Mailing Address - Street 1:PO BOX 14129
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47601 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1233
Practice Address - Country:US
Practice Address - Phone:248-465-3372
Practice Address - Fax:248-465-4765
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2024000132363LG0600X
MI47044413636363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124894050OtherNPI