Provider Demographics
NPI:1861951394
Name:FRISQUE, ERIC (PTA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FRISQUE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 W LEATHER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-2270
Mailing Address - Country:US
Mailing Address - Phone:920-569-9497
Mailing Address - Fax:
Practice Address - Street 1:428 N 6TH ST
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-1425
Practice Address - Country:US
Practice Address - Phone:715-453-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2715-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant