Healthcare Provider Details

I. General information

NPI: 1669094330
Provider Name (Legal Business Name): JANE EDNA SMETANA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 N MAYFAIR RD STE 300
WAUWATOSA WI
53222-4306
US

IV. Provider business mailing address

2999 N MAYFAIR RD STE 300
WAUWATOSA WI
53222-4306
US

V. Phone/Fax

Practice location:
  • Phone: 414-479-3737
  • Fax: 414-479-3733
Mailing address:
  • Phone: 414-479-3737
  • Fax: 414-479-3733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number584-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: