Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 1765-19 | WI |
NPI | 1003194630 |
---|---|
Provider Name | Heather Tanko |
First Address | Bloomer, WI 54724-1512 |
Second Address | Bloomer, WI 54724-1512 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2011 |
Last Update Date | 01/08/2011 |