Provider Demographics
NPI:1467918391
Name:WHARTON, ROBERTO A (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:A
Last Name:WHARTON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-4334
Mailing Address - Country:US
Mailing Address - Phone:701-683-6458
Mailing Address - Fax:
Practice Address - Street 1:905 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4334
Practice Address - Country:US
Practice Address - Phone:701-683-6458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1229A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation