MEDICARE: JUSTIN L STAKER PT

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	225100000X	Physical Therapist	7647	MN

General Provider Information

NPI Number	:	1700838810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN L STAKER PT

Provider Business Mailing Address
First Line	:	1836 SOUTH AVE
Second Line	:
City	:	LA CROSSE
State	:	WI
Zip	:	54601-5429
Country	:	US
Telephone Number	:	608-782-7300
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 RIVERFRONT
Second Line	:
City	:	WINONA
State	:	MN
Zip	:	55987-3456
Country	:	US
Telephone Number	:	507-454-8700
Fax Number	:

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	07/08/2007

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Directions to “ JUSTIN L STAKER PT” Practice Location

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