Healthcare Provider Details

I. General information

NPI: 1457918195
Provider Name (Legal Business Name): SIERRA BRANSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 SHELBY RD
LA CROSSE WI
54601-8037
US

IV. Provider business mailing address

N1418 TIMBER VALLEY RD
LA CROSSE WI
54601-2172
US

V. Phone/Fax

Practice location:
  • Phone: 608-519-9801
  • Fax:
Mailing address:
  • Phone: 608-787-6386
  • Fax: 608-788-4543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2054-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: