Healthcare Provider Details

I. General information

NPI: 1619468444
Provider Name (Legal Business Name): XAVIER PATTERSON COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

S77W12929 MCSHANE DR
MUSKEGO WI
53150
US

IV. Provider business mailing address

400 N RICHMOND ST UNIT 308
APPLETON WI
54911-4697
US

V. Phone/Fax

Practice location:
  • Phone: 414-529-0100
  • Fax:
Mailing address:
  • Phone: 920-574-1677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5486-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: