Basic Information
| Provider Information | |||||||||
| NPI: | 1508913013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANSKE | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 261 N PARK ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND CENTER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535812208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086476321 | ||||||||
| FaxNumber: | 6086477929 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND CENTER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535811914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086476321 | ||||||||
| FaxNumber: | 6086477929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 111-039 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.