Provider Demographics
NPI:1184869455
Name:WEISPFENNING, MICHAEL JON (DPT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JON
Last Name:WEISPFENNING
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891-9457
Mailing Address - Country:US
Mailing Address - Phone:218-340-0263
Mailing Address - Fax:
Practice Address - Street 1:3 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:WI
Practice Address - Zip Code:54891-9457
Practice Address - Country:US
Practice Address - Phone:218-340-0263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11040-024225100000X
MN8112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36184600Medicaid