Healthcare Provider Details

I. General information

NPI: 1699014225
Provider Name (Legal Business Name): THOMAS WILHAU KARLS NIEHAUS P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 COUNTY ROAD CH
DODGEVILLE WI
53533-9108
US

IV. Provider business mailing address

4094 KEEWATIN TRL
VERONA WI
53593-8605
US

V. Phone/Fax

Practice location:
  • Phone: 608-935-3321
  • Fax:
Mailing address:
  • Phone: 608-833-2340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number479-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: