Provider Demographics
NPI:1265517296
Name:ROSSER, RUTHANNE LYDIA (PT)
Entity type:Individual
Prefix:MRS
First Name:RUTHANNE
Middle Name:LYDIA
Last Name:ROSSER
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:W6074 WINDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-8427
Mailing Address - Country:US
Mailing Address - Phone:715-453-7906
Mailing Address - Fax:
Practice Address - Street 1:202 W MOHAWK DR
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-2215
Practice Address - Country:US
Practice Address - Phone:715-453-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4573-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36124600Medicaid
000281264Medicare PIN