MEDICARE: MS. LISA M NOLDEN PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	160004668	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	769380	OTHER	IL	MEDICARE GROUP PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	160004668	OTHER	IL	IL LICENSE

General Provider Information

NPI Number	:	1093029092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA M NOLDEN PTA

Provider Business Mailing Address
First Line	:	PO BOX 2176
Second Line	:	DEPT 5389
City	:	MILWAUKEE
State	:	WI
Zip	:	53201-2176
Country	:	US
Telephone Number	:	815-713-2600
Fax Number	:	815-654-8020

Provider Business Practice Location Address
First Line	:	1663 BELVIDERE RD
Second Line	:
City	:	BELVIDERE
State	:	IL
Zip	:	61008-9306
Country	:	US
Telephone Number	:	815-544-0040
Fax Number	:	815-544-0048

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2010
Last Update Date	:	08/02/2010

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