Provider Demographics
NPI:1518961242
Name:BRANES, ROGER K (PT)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:K
Last Name:BRANES
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 851
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-0851
Mailing Address - Country:US
Mailing Address - Phone:715-483-9221
Mailing Address - Fax:715-483-1743
Practice Address - Street 1:111 THOMPSON PKWY
Practice Address - Street 2:
Practice Address - City:ST CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024
Practice Address - Country:US
Practice Address - Phone:715-483-9221
Practice Address - Fax:715-483-1743
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2172024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40110500Medicaid