Provider Demographics
NPI:1790922110
Name:WIEGEL, MIRANDA JO (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:JO
Last Name:WIEGEL
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:N9193 STATE ROAD 78
Mailing Address - Street 2:
Mailing Address - City:BLANCHARDVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53516-9632
Mailing Address - Country:US
Mailing Address - Phone:608-558-2382
Mailing Address - Fax:
Practice Address - Street 1:41 RICKEL RD
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1840
Practice Address - Country:US
Practice Address - Phone:608-837-8529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1435-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant