Provider Demographics
NPI:1033482799
Name:GATDULA, AMBER (PTA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:GATDULA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-3110
Mailing Address - Country:US
Mailing Address - Phone:608-214-8257
Mailing Address - Fax:
Practice Address - Street 1:2628 14TH STREET
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566
Practice Address - Country:US
Practice Address - Phone:608-214-8257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1318-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant