Idaho
Division of Occupational and Professional Licenses
ROBERT PROVENZANO
Board Of Medicine
License number
M-11205
Date granted
01/19/2011
Date expires
06/30/2017
Class
Board Of Medicine
Status
Renewed
Address
22201 MOROSS ROAD GROSSE POINTE MI 48236
idaholicensing.com
ID 48360565
LAST UPDATED 2024-02-11 08:40:51 UTC
LAST UPDATED 2024-02-11 08:40:51 UTC
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