Healthcare Provider Details

I. General information

NPI: 1477882769
Provider Name (Legal Business Name): THOMAS RICHARD TOMASZEWSKI PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 WELLS ST SUITE 200
DELAFIELD WI
53018-1409
US

IV. Provider business mailing address

1806 OAK LEAF DR
GREEN BAY WI
54304-1779
US

V. Phone/Fax

Practice location:
  • Phone: 479-201-2844
  • Fax:
Mailing address:
  • Phone: 920-497-8490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number757-19
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number757-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: