Provider Demographics
NPI:1235611211
Name:WEDEMEYER, CHARISMA (PTA)
Entity Type:Individual
Prefix:
First Name:CHARISMA
Middle Name:
Last Name:WEDEMEYER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CHARISMA
Other - Middle Name:
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:10609 W IH 10 STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1673
Mailing Address - Country:US
Mailing Address - Phone:210-344-5437
Mailing Address - Fax:210-340-1259
Practice Address - Street 1:10609 W IH 10 STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1673
Practice Address - Country:US
Practice Address - Phone:210-344-5437
Practice Address - Fax:210-340-1259
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173913801Medicaid