Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 17468 | MA |
NPI | 1225098544 |
---|---|
Provider Name | Mr. Michael Roger Garrett |
First Address | Nantucket, MA 02554-3680 |
Second Address | Nantucket, MA 02554-3680 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2006 |
Last Update Date | 21/10/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
17468 | MEDICAL LICENSE (01) | MA |
650041 | TUFTS (01) | MA |
7261 | MEDICAL LICENSE (01) | CO |
Y68819 | BLUE CROSS OF MA (01) | MA |