Provider Demographics
NPI:1134977242
Name:MESAR, LAUREN TYLER (PTA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:TYLER
Last Name:MESAR
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 1:1108 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3520
Mailing Address - Country:US
Mailing Address - Phone:715-937-2602
Mailing Address - Fax:
Practice Address - Street 1:2815 COUNTY HIGHWAY I
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2656
Practice Address - Country:US
Practice Address - Phone:715-723-9341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4163-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant