MEDICARE: MRS. TAMMY LUELLA GAGNON 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	1129-019	WI

General Provider Information

NPI Number	:	1487953592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TAMMY LUELLA GAGNON PTA

Provider Business Mailing Address
First Line	:	932 W 5TH ST
Second Line	:
City	:	NEKOOSA
State	:	WI
Zip	:	54457-1075
Country	:	US
Telephone Number	:	715-886-2973
Fax Number	:

Provider Business Practice Location Address
First Line	:	W6990 S SILVER LAKE RD
Second Line	:
City	:	WAUTOMA
State	:	WI
Zip	:	54982-5890
Country	:	US
Telephone Number	:	920-787-4766
Fax Number	:

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

Provider Enumeration Date	:	03/16/2011
Last Update Date	:	03/16/2011

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