Provider Demographics
NPI:1316231616
Name:STIMAC, MICHAEL (PTA, LAT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:STIMAC
Suffix:
Gender:M
Credentials:PTA, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1733
Mailing Address - Country:US
Mailing Address - Phone:920-573-0983
Mailing Address - Fax:
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-748-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1830-19225200000X
WI1435-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer