Provider Demographics
NPI:1497872790
Name:SYTSMA, PETER A (PT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:SYTSMA
Suffix:
Gender:M
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:PO BOX 11
Mailing Address - Street 2:3010 HIGHWAY 141
Mailing Address - City:POUND
Mailing Address - State:WI
Mailing Address - Zip Code:54161
Mailing Address - Country:US
Mailing Address - Phone:920-897-4799
Mailing Address - Fax:920-897-4128
Practice Address - Street 1:3010 HIGHWAY 141
Practice Address - Street 2:
Practice Address - City:POUND
Practice Address - State:WI
Practice Address - Zip Code:54161
Practice Address - Country:US
Practice Address - Phone:920-897-4799
Practice Address - Fax:920-897-4128
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI864024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40133900Medicaid
WI40133900Medicaid