Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant |
NPI | 1013476233 |
---|---|
Provider Name | Bill Graham |
First Address | Mason, MI 48854-1611 |
Second Address | Lansing, MI 48912-4649 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/03/2019 |
Last Update Date | 18/03/2019 |