Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 3849 | WI |
N | 2251S0007X | Physical Therapist - Sports | 7122 | MN |
NPI | 1144225517 |
---|---|
Provider Name | Jonathan S Straker |
First Address | La Crosse, WI 54601-5429 |
Second Address | Onalaska, WI 54650-8512 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2005 |
Last Update Date | 15/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
40164800 | (05) | WI |
P97944 | (02) |