Provider Demographics
NPI:1912685215
Name:MITRA, SUBHAM (RN)
Entity Type:Individual
Prefix:
First Name:SUBHAM
Middle Name:
Last Name:MITRA
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 1:31185 WELLINGTON DR APT 28203
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-4193
Mailing Address - Country:US
Mailing Address - Phone:248-946-6248
Mailing Address - Fax:
Practice Address - Street 1:43825 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2551
Practice Address - Country:US
Practice Address - Phone:248-788-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704370209163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse