Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 5951001352 | MI |
Y | 222Z00000X | Podiatrist | 5951001352 | MI |
NPI | 1073075222 |
---|---|
Provider Name | Patrick Derby |
First Address | Clinton Township, MI 48038-3504 |
Second Address | Clinton Township, MI 48038-3504 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2019 |
Last Update Date | 29/03/2021 |