Provider Demographics
NPI:1689647828
Name:VETTE BURGARDT, PAMELA GERDA (PT)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:GERDA
Last Name:VETTE BURGARDT
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 1:1020 HILL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3016
Mailing Address - Country:US
Mailing Address - Phone:920-206-4935
Mailing Address - Fax:920-206-4986
Practice Address - Street 1:1020 HILL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3016
Practice Address - Country:US
Practice Address - Phone:920-206-4935
Practice Address - Fax:920-206-4986
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4577024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391126946OtherTAX ID NUMBER