Provider Demographics
NPI:1063552073
Name:WOLTMAN, MISTY (PT)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:WOLTMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 W. NORTH FRONT ST.
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803
Mailing Address - Country:US
Mailing Address - Phone:308-381-2424
Mailing Address - Fax:308-381-3646
Practice Address - Street 1:3213 W. NORTH FRONT ST.
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803
Practice Address - Country:US
Practice Address - Phone:308-381-2424
Practice Address - Fax:308-381-3646
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-0707622-00Medicaid
NE47-0707622-01Medicaid
NE47-0707622-01Medicaid