Provider Demographics
NPI:1629402730
Name:WIERSCHKE, SAMANTHA ANN (PT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:WIERSCHKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8619 S HOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-2919
Mailing Address - Country:US
Mailing Address - Phone:414-856-1888
Mailing Address - Fax:414-727-5779
Practice Address - Street 1:5231 W VILLARD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4368
Practice Address - Country:US
Practice Address - Phone:414-856-1888
Practice Address - Fax:414-727-5779
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12326-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK100249753Medicare PIN
WIK400249787Medicare PIN