Provider Demographics
NPI:1053989491
Name:WEGNER, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WEGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:PITTSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54466-9507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5855 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:PITTSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54466-9507
Practice Address - Country:US
Practice Address - Phone:715-213-3796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3178-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant