Provider Demographics
NPI:1912238494
Name:IVASKA, MEGAN (PT, DPT, CLT)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:
Last Name:IVASKA
Suffix:
Gender:F
Credentials:PT, DPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3982 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-483-9933
Mailing Address - Fax:260-483-9931
Practice Address - Street 1:3982 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1712
Practice Address - Country:US
Practice Address - Phone:260-483-9933
Practice Address - Fax:260-483-9931
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009601A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN250440Medicare UPIN