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General NPI Number Information
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NPI Number | 1457803850
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Entity Type | Individual
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Provider Name | JOSEPH MICHAEL LIDESTER P.T.A.
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Gender | Male
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Dates
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Enumeration Date | 11/01/2016
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Last Update Date | 11/01/2016
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Provider Practice Location Address
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Address Line | 9047 W GREENFIELD AVE
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City | MILWAUKEE
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State | WI
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Zip | 53214-2808
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Country | US
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Telephone | 414-453-9290
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Fax |
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Provider Business Mailing Address
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Address Line | 3901 HARMONY CT
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City | ZION
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State | IL
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Zip | 60099-9548
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Country | US
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Telephone | 262-902-9780
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2578-19
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License Number State | WI
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