Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | ||
Y | 222Z00000X | Podiatrist |
NPI | 1043736424 |
---|---|
Provider Name | John Roberts-Kinyon |
First Address | Grosse Pointe Park, MI 48230-1026 |
Second Address | Grosse Pointe Park, MI 48230-1026 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2017 |
Last Update Date | 17/08/2017 |