Provider Demographics
NPI:1194438051
Name:WAFER, CHARLES ANTHONY-ERIK
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANTHONY-ERIK
Last Name:WAFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11391 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-1302
Mailing Address - Country:US
Mailing Address - Phone:313-208-1006
Mailing Address - Fax:
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-208-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005482225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant