MEDICARE: EVA ACOSTA P.T.A

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	28419	WI

General Provider Information

NPI Number	:	1639447048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVA ACOSTA P.T.A

Provider Business Mailing Address
First Line	:	1222 N CASS ST UNIT 388
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-2965
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1222 N CASS ST UNIT 388
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-2965
Country	:	US
Telephone Number	:	414-224-0695
Fax Number	:

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

Provider Enumeration Date	:	12/13/2011
Last Update Date	:	12/13/2011

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