Basic Information
| Provider Information | |||||||||
| NPI: | 1982717898 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MEYER | ||||||||
| FirstName: | TINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 WHISPERING CREEK CT | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543036029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204960304 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1040 PILGRIM WAY | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543045028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204053522 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 03/06/2012 | ||||||||
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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 | 225200000X | 449-19 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 40317600 | 05 | WI | MEDICAID |