Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5501012837 | MI |
NPI | 1003070632 |
---|---|
Provider Name | Pamela Brioso Gonzales-Lanac |
First Address | Troy, MI 48085-1117 |
Second Address | Troy, MI 48085-1117 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2008 |
Last Update Date | 23/02/2018 |