Provider Demographics
NPI:1023859543
Name:NYAMWARO, JESSE (DPM)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:NYAMWARO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1303 S LINDEN RD STE D
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3442
Practice Address - Country:US
Practice Address - Phone:810-230-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5951001557213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist