Healthcare Provider Details

I. General information

NPI: 1962036186
Provider Name (Legal Business Name): TIMOTHY LEE BUECHNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 2ND AVE
NEW GLARUS WI
53574-9776
US

IV. Provider business mailing address

30 POND VIEW WAY
FITCHBURG WI
53711-4954
US

V. Phone/Fax

Practice location:
  • Phone: 608-527-4390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3039-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: