MEDICARE: MR. SANTANA ROHAN DEACON MPT

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	2251S0007X	Sports Physical Therapist	10088-024	WI

General Provider Information

NPI Number	:	1568632818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SANTANA ROHAN DEACON MPT

Provider Business Mailing Address
First Line	:	1626 W FOND DU LAC AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1228
Country	:	US
Telephone Number	:	414-436-5155
Fax Number	:

Provider Business Practice Location Address
First Line	:	1626 W FOND DU LAC AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1228
Country	:	US
Telephone Number	:	414-517-6585
Fax Number	:

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

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	07/28/2020

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