Healthcare Provider Details

I. General information

NPI: 1689647828
Provider Name (Legal Business Name): PAMELA GERDA VETTE BURGARDT PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 HILL ST
WATERTOWN WI
53098-3016
US

IV. Provider business mailing address

1020 HILL ST
WATERTOWN WI
53098-3016
US

V. Phone/Fax

Practice location:
  • Phone: 920-206-4935
  • Fax: 920-206-4986
Mailing address:
  • Phone: 920-206-4935
  • Fax: 920-206-4986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4577024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: