Provider Demographics
NPI:1790853786
Name:MACHOTKA, LISA M (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:MACHOTKA
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 1:225000 HUMMINGBIRD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2950
Mailing Address - Country:US
Mailing Address - Phone:715-359-6442
Mailing Address - Fax:715-393-0390
Practice Address - Street 1:1767 PARK AVE
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-4301
Practice Address - Country:US
Practice Address - Phone:715-344-1260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5855-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40401400Medicaid
WI40401400Medicaid