Provider Demographics
NPI:1346614229
Name:KRUEGER, MIRANDA (PTA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:KRUEGER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 BARBICAN AVE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-4186
Mailing Address - Country:US
Mailing Address - Phone:715-393-0400
Mailing Address - Fax:715-393-0938
Practice Address - Street 1:4810 BARBICAN AVE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-4186
Practice Address - Country:US
Practice Address - Phone:715-393-0400
Practice Address - Fax:715-393-0938
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2338-192251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics