Provider Demographics
NPI:1447407341
Name:MODERSON, ANGELA JEAN (PTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:JEAN
Last Name:MODERSON
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 1:717 E ALFRED ST
Mailing Address - Street 2:
Mailing Address - City:WEYAUWEGA
Mailing Address - State:WI
Mailing Address - Zip Code:54983-9024
Mailing Address - Country:US
Mailing Address - Phone:920-867-3121
Mailing Address - Fax:920-867-3997
Practice Address - Street 1:717 E ALFRED ST
Practice Address - Street 2:
Practice Address - City:WEYAUWEGA
Practice Address - State:WI
Practice Address - Zip Code:54983-9024
Practice Address - Country:US
Practice Address - Phone:920-867-3121
Practice Address - Fax:920-867-3997
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI856-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant