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NPI Code Detail

MEDICARE: MRS. MIRANDA JO WIEGEL PTA

MEDICARE: MRS. MIRANDA JO WIEGEL 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
1225200000XPhysical Therapy Assistant1435-019WI

General Provider Information

NPI Number : 1790922110
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MIRANDA JO WIEGEL PTA
Provider Business Mailing Address
First Line : N9193 STATE ROAD 78
Second Line :
City : BLANCHARDVILLE
State : WI
Zip : 53516-9632
Country : US
Telephone Number : 608-558-2382
Fax Number :
Provider Business Practice Location Address
First Line : 41 RICKEL RD
Second Line :
City : SUN PRAIRIE
State : WI
Zip : 53590-1840
Country : US
Telephone Number : 608-837-8529
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/08/2009
Last Update Date : 01/08/2009

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