Provider Demographics
NPI:1982287454
Name:SIKE, VINCENT (PTA)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:SIKE
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 1:1000 RADIO DR STE 120
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-8410
Mailing Address - Country:US
Mailing Address - Phone:651-753-6100
Mailing Address - Fax:
Practice Address - Street 1:1000 RADIO DR STE 120
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-8410
Practice Address - Country:US
Practice Address - Phone:651-753-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1778225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant