Provider Demographics
NPI:1740683069
Name:FAJARDO, MOISES
Entity type:Individual
Prefix:
First Name:MOISES
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MOISES ROMEO
Other - Middle Name:
Other - Last Name:FAJARDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2445 CLAYMONT DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2493
Mailing Address - Country:US
Mailing Address - Phone:248-792-7114
Mailing Address - Fax:
Practice Address - Street 1:1402 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-1499
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267838363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily