Provider Demographics
NPI:1538444351
Name:PATZKE, SANDRA JEAN (PTA)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JEAN
Last Name:PATZKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W7738 STATE QUARRY LN
Mailing Address - Street 2:
Mailing Address - City:AMBERG
Mailing Address - State:WI
Mailing Address - Zip Code:54102-9250
Mailing Address - Country:US
Mailing Address - Phone:715-759-5623
Mailing Address - Fax:715-759-5623
Practice Address - Street 1:W7738 STATE QUARRY LN
Practice Address - Street 2:
Practice Address - City:AMBERG
Practice Address - State:WI
Practice Address - Zip Code:54102-9250
Practice Address - Country:US
Practice Address - Phone:715-759-5623
Practice Address - Fax:715-759-5623
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1801-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP320-7905-9842-02OtherDRIVERS LICENSE