Provider Demographics
NPI:1114139821
Name:AU, DONNA M (PT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:AU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W4294 HILLVIEW LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-9714
Mailing Address - Country:US
Mailing Address - Phone:920-699-2340
Mailing Address - Fax:
Practice Address - Street 1:2895 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-3743
Practice Address - Country:US
Practice Address - Phone:262-782-9013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1268-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40094100Medicaid