Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251S0007X | Physical Therapist - Sports | 14657-24 | WI |
Y | 2251X0800X | Physical Therapist - Orthopedic | 14657-24 | WI |
NPI | 1194316455 |
---|---|
Provider Name | Jameson Matthew Otte |
First Address | Sheboygan, WI 53083-4932 |
Second Address | Sheboygan, WI 53083-4932 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2021 |
Last Update Date | 29/01/2021 |