Provider Demographics
NPI:1417075698
Name:VANDER ARK, SHARON L (PT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:L
Last Name:VANDER ARK
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:W4267 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-8593
Mailing Address - Country:US
Mailing Address - Phone:920-948-6431
Mailing Address - Fax:
Practice Address - Street 1:210 WISCONSIN AMERICAN DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2999
Practice Address - Country:US
Practice Address - Phone:920-907-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40309900Medicaid