Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 5502005311 | MI |
NPI | 1013432178 |
---|---|
Provider Name | Derek Jordan Adams |
First Address | Three Rivers, MI 49093-8352 |
Second Address | Three Rivers, MI 49093-8350 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2017 |
Last Update Date | 10/08/2017 |