Provider Demographics
NPI:1649557513
Name:KINYON, MICHAEL WILLIAM (LPTA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:KINYON
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4136
Mailing Address - Country:US
Mailing Address - Phone:810-966-9102
Mailing Address - Fax:810-966-9104
Practice Address - Street 1:1702 WATER ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4136
Practice Address - Country:US
Practice Address - Phone:810-966-9102
Practice Address - Fax:810-966-9104
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-07
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2085107225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant