Healthcare Provider Details

I. General information

NPI: 1457376626
Provider Name (Legal Business Name): STEVE NELSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 N PORT WASHINGTON RD
MEQUON WI
53097-2416
US

IV. Provider business mailing address

125 S ORCHARD ST
THIENSVILLE WI
53092-1872
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-7444
  • Fax: 262-243-7486
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number698-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: