Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 1133-019 | WI |
NPI | 1013111012 |
---|---|
Provider Name | Adam Kupietz |
First Address | Burlington, WI 53105-1828 |
Second Address | Burlington, WI 53105-1828 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
36128500 | (05) | WI |