MEDICARE: MRS. TRACIE ANNE VIDAS 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	1101-19	WI

General Provider Information

NPI Number	:	1760742589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACIE ANNE VIDAS PTA

Provider Business Mailing Address
First Line	:	4313 WASHINGTON RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-1501
Country	:	US
Telephone Number	:	262-654-2800
Fax Number	:	262-654-2800

Provider Business Practice Location Address
First Line	:	4313 WASHINGTON RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-1501
Country	:	US
Telephone Number	:	262-654-2800
Fax Number	:	262-654-2800

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

Provider Enumeration Date	:	05/26/2012
Last Update Date	:	05/26/2012

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Directions to “ MRS. TRACIE ANNE VIDAS PTA” Practice Location

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