Basic Information
| Provider Information | |||||||||
| NPI: | 1861951394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRISQUE | ||||||||
| FirstName: | ERIC | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 465 W LEATHER AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | TOMAHAWK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544872270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205699497 | ||||||||
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| Practice Location | |||||||||
| Address1: | 428 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TOMAHAWK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544871425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154532511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2019 | ||||||||
| LastUpdateDate: | 03/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2715-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.