Provider Demographics
NPI:1770117301
Name:ANANGFAC, ERIC FOZE
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:FOZE
Last Name:ANANGFAC
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 1:352 N ROSS ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:MI
Mailing Address - Zip Code:48612-8165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:352 N ROSS ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:MI
Practice Address - Zip Code:48612-8165
Practice Address - Country:US
Practice Address - Phone:989-435-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302046609183500000X
MI4704405947363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No183500000XPharmacy Service ProvidersPharmacist