Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 5101017592 | MI |
NPI | 1053573048 |
---|---|
Provider Name | Rebecca Wyatt |
First Address | East Lansing, MI 48824-7015 |
Second Address | Lansing, MI 48912-1837 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2008 |
Last Update Date | 16/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1053573048 | (05) | MI |