Provider Demographics
NPI:1326811050
Name:DUCOMMUN, TERA (PTA)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:DUCOMMUN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:TERA
Other - Middle Name:
Other - Last Name:CONWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 27TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW AUBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54757-8787
Mailing Address - Country:US
Mailing Address - Phone:715-205-8746
Mailing Address - Fax:
Practice Address - Street 1:1405 TRUAX BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-1474
Practice Address - Country:US
Practice Address - Phone:715-552-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3333-19208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation