Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 5501017856 | MI |
NPI | 1033657390 |
---|---|
Provider Name | Marissa Thomas |
First Address | Grand Rapids, MI 49503-5917 |
Second Address | Greenville, MI 48838-8259 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2017 |
Last Update Date | 09/08/2017 |