Provider Demographics
NPI:1760985402
Name:PRIESTAP, ROBERT SR (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:PRIESTAP
Suffix:SR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1592
Mailing Address - Country:US
Mailing Address - Phone:989-731-2341
Mailing Address - Fax:989-731-7787
Practice Address - Street 1:825 N CENTER AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1592
Practice Address - Country:US
Practice Address - Phone:989-731-2341
Practice Address - Fax:989-731-7787
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist