Provider Demographics
NPI:1578688081
Name:MATSKO, KIMBERLY ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:MATSKO
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 1:813 SILVER SAGE TRAIL
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562
Mailing Address - Country:US
Mailing Address - Phone:608-469-3794
Mailing Address - Fax:
Practice Address - Street 1:813 SILVER SAGE TRL
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-5684
Practice Address - Country:US
Practice Address - Phone:608-469-3794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1902-19174400000X
IL160.005474174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL160.005474OtherSTATE LICENSE
PATEI000058OtherSTATE LICENSE
WI1902-19OtherSTATE LICENSE