Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251S0007X | Physical Therapist - Sports | 5501009637 | MI |
Y | 2251X0800X | Physical Therapist - Orthopedic | 5501009637 | MI |
NPI | 1033610886 |
---|---|
Provider Name | Derek Chan |
First Address | Flat Rock, MI 48134-1843 |
Second Address | Detroit, MI 48202-3006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2018 |
Last Update Date | 06/04/2021 |