Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5501016584 | MI |
N | 225100000X | Physical Therapist | PTL.0012446 | CO |
NPI | 1003247891 |
---|---|
Provider Name | Ryan Sanders Gary |
First Address | Grand Rapids, MI 49506-1674 |
Second Address | Grand Rapids, MI 49506-1674 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2013 |
Last Update Date | 07/11/2014 |