Healthcare Provider Details

I. General information

NPI: 1194637314
Provider Name (Legal Business Name): TAMARA WADE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

972 W MAIN ST
SUN PRAIRIE WI
53590-2039
US

IV. Provider business mailing address

972 W MAIN ST
SUN PRAIRIE WI
53590-2039
US

V. Phone/Fax

Practice location:
  • Phone: 608-318-0052
  • Fax: 608-413-0552
Mailing address:
  • Phone: 608-318-0052
  • Fax: 608-413-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4160-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: