Provider Demographics
NPI:1144587965
Name:TEZAK, WYNNE (PT)
Entity Type:Individual
Prefix:
First Name:WYNNE
Middle Name:
Last Name:TEZAK
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 1:175 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1419
Mailing Address - Country:US
Mailing Address - Phone:989-884-3128
Mailing Address - Fax:
Practice Address - Street 1:348 LONG RAPIDS PLZ
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1374
Practice Address - Country:US
Practice Address - Phone:989-358-8086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist