Healthcare Provider Details

I. General information

NPI: 1730636184
Provider Name (Legal Business Name): PAYNE ANDREW ROBERTSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 07/21/2026
Certification Date:
Deactivation Date: 08/18/2017
Reactivation Date: 07/21/2026

III. Provider practice location address

1230 HASLETT RD APT A15
EAST LANSING MI
48823-2869
US

IV. Provider business mailing address

1230 HASLETT RD APT A15
EAST LANSING MI
48823-2869
US

V. Phone/Fax

Practice location:
  • Phone: 734-660-1072
  • Fax:
Mailing address:
  • Phone: 734-660-1072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: