Provider Demographics
NPI:1598039943
Name:PETHAN, SCOTT MICHAEL (MS, BSN, RN)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:PETHAN
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Gender:M
Credentials:MS, BSN, RN
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Mailing Address - Street 1:2700 W 9TH AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7247
Mailing Address - Country:US
Mailing Address - Phone:920-236-1835
Mailing Address - Fax:920-223-1182
Practice Address - Street 1:2700 W 9TH AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7247
Practice Address - Country:US
Practice Address - Phone:920-236-1835
Practice Address - Fax:920-223-1182
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI136064-30224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist