Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 5501012929 | MI |
NPI | 1215324991 |
---|---|
Provider Name | Jais Mathews |
First Address | Novi, MI 48375-3953 |
Second Address | Novi, MI 48375-3953 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2015 |
Last Update Date | 21/04/2015 |