Healthcare Provider Details

I. General information

NPI: 1699653170
Provider Name (Legal Business Name): ALEXANDER SHUTTER DPT
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2025
Last Update Date: 08/23/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1772 RIVERSIDE DR
SUAMICO WI
54173-8100
US

IV. Provider business mailing address

1772 RIVERSIDE DR
SUAMICO WI
54173-8100
US

V. Phone/Fax

Practice location:
  • Phone: 920-838-5483
  • Fax:
Mailing address:
  • Phone: 920-838-5483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number1745324
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: