Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 5502003868 | MI |
NPI | 1003474768 |
---|---|
Provider Name | Magan Rivera |
First Address | Bellevue, MI 49021-1336 |
Second Address | Bellevue, MI 49021-1336 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2019 |
Last Update Date | 29/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
19514952 | (05) | MI |