Provider Demographics
NPI:1932988987
Name:BAMBENEK, NORMAN (PTA)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:
Last Name:BAMBENEK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 WINTERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-9046
Mailing Address - Country:US
Mailing Address - Phone:715-323-2105
Mailing Address - Fax:
Practice Address - Street 1:1702 S RIVER RD
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-5648
Practice Address - Country:US
Practice Address - Phone:608-756-0344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4126-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant