| Doctor Name: | TORY DERISO |
| NPI Number: | 1730573247 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 4703108814 |
| Business Practice Address: | 27026 Meadowood Dr Apt 204 Wixom, MI - 483933271 |
| Business Phone Number: | 2487737687 |
| Business Fax Number: | |
| Mailing Address: | 27026 Meadowood Dr Apt 204, WIXOM |
| State: | MI |
| Postal Code: | 483933271 |
| Phone Number: | 2487737687 |
| Fax Number: | |
| NPI Enumeration Date: | 03/23/2015 |
| NPI Last Update Date: | 03/23/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 164W00000X |
| License Number: | 4703108814 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Nursing Service Providers |
| Taxonomy Classification: | Licensed Practical Nurse |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual with post-high school vocational training and practical experience in the provision of nursing care at a level less than that required for certification as a Registered Nurse. Requirements for education, experience, licensure, and job responsibilities vary among the states. |