Provider Demographics
NPI:1265721781
Name:ANDERSON, KRISTA (PTA)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:ANDERSON
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:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:888-201-1040
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:417 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WI
Practice Address - Zip Code:54005
Practice Address - Country:US
Practice Address - Phone:715-263-4103
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1712-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1265721781Medicaid