Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant |
NPI | 1023128766 |
---|---|
Provider Name | Michael Leeper |
First Address | Melbourne, FL 32940-6372 |
Second Address | Melbourne, FL 32940-8147 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PTA19023 | LICENSE # (01) | FL |