Healthcare Provider Details

I. General information

NPI: 1205284528
Provider Name (Legal Business Name): BOYANA B MERCER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 WILLOW ST
PESHTIGO WI
54157-9200
US

IV. Provider business mailing address

701 WILLOW ST
PESHTIGO WI
54157-9200
US

V. Phone/Fax

Practice location:
  • Phone: 715-582-1044
  • Fax: 715-582-0803
Mailing address:
  • Phone: 715-582-0144
  • Fax: 715-582-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2079
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: