MEDICARE: MRS. LISA M MACHOTKA 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	5855-24	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790853786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA M MACHOTKA PT

Provider Business Mailing Address
First Line	:	225000 HUMMINGBIRD RD STE 100
Second Line	:
City	:	WAUSAU
State	:	WI
Zip	:	54401-2950
Country	:	US
Telephone Number	:	715-359-6442
Fax Number	:	715-393-0390

Provider Business Practice Location Address
First Line	:	1767 PARK AVE
Second Line	:
City	:	PLOVER
State	:	WI
Zip	:	54467-4301
Country	:	US
Telephone Number	:	715-344-1260
Fax Number	:

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

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	06/07/2022

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