Provider Demographics
NPI:1548821556
Name:HOUSTON, TY R (FNP)
Entity type:Individual
Prefix:
First Name:TY
Middle Name:R
Last Name:HOUSTON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13100 CORBETT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-2081
Mailing Address - Country:US
Mailing Address - Phone:313-575-5542
Mailing Address - Fax:
Practice Address - Street 1:13100 CORBETT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-2081
Practice Address - Country:US
Practice Address - Phone:313-575-5542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704184826363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily