Basic Information
| Provider Information | |||||||||
| NPI: | 1760533749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STERGAR | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P. T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | ROBERTA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7361 PRAIRIE FALCON RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022430515 | ||||||||
| FaxNumber: | 7022432019 | ||||||||
| Practice Location | |||||||||
| Address1: | 7361 PRAIRIE FALCON RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022430515 | ||||||||
| FaxNumber: | 7022432019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 10/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070012031 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2899 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11581828 | 01 | IL | CAQH PROVIDER ID | OTHER | 2899 | 01 | NV | NEVADA STATE BOARD OF PHYSICAL THERAPY EXAMINERS | OTHER |