Basic Information
| Provider Information | |||||||||
| NPI: | 1487260774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUOG | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WATERS | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 612 EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530954114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173064864 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | W227N16857 TILLIE LAKE CT | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530379000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623656170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2020 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12158 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.