Provider Demographics
NPI:1053942730
Name:SANDER, NOAH S (PTA)
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:S
Last Name:SANDER
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 1:511 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:CUBA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53807-1629
Mailing Address - Country:US
Mailing Address - Phone:608-732-1545
Mailing Address - Fax:
Practice Address - Street 1:4135 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2628
Practice Address - Country:US
Practice Address - Phone:563-583-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096407225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant