Provider Demographics
NPI:1114512647
Name:SIERCK, STEW (PTA)
Entity Type:Individual
Prefix:
First Name:STEW
Middle Name:
Last Name:SIERCK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6216 WILLOW CREST DR APT 202
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2136
Mailing Address - Country:US
Mailing Address - Phone:712-260-4820
Mailing Address - Fax:
Practice Address - Street 1:1204 LINDEN ST
Practice Address - Street 2:
Practice Address - City:DALLAS CENTER
Practice Address - State:IA
Practice Address - Zip Code:50063-1052
Practice Address - Country:US
Practice Address - Phone:515-992-3735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-06
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096727225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant