Healthcare Provider Details

I. General information

NPI: 1205568763
Provider Name (Legal Business Name): GOWA TUNDUP LAMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 S 21ST ST
MANITOWOC WI
54220-6380
US

IV. Provider business mailing address

1223 N 6TH ST
SHEBOYGAN WI
53081-3515
US

V. Phone/Fax

Practice location:
  • Phone: 920-684-7171
  • Fax:
Mailing address:
  • Phone: 209-631-5956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3101
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: