Basic Information
| Provider Information | |||||||||
| NPI: | 1700184272 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSER | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | CRYSTAL | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 PILGRIM WAY | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543045028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204053522 | ||||||||
| FaxNumber: | 9204053523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 PILGRIM WAY | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543045028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204053522 | ||||||||
| FaxNumber: | 9204053523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 4763-027 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 4763-027 | 01 | WI | STATE OF WISCONSIN | OTHER |