Provider Demographics
NPI:1063948636
Name:CORONADO, STEVEN HARRY (PTA)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:HARRY
Last Name:CORONADO
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 1:610 MCEVOY ST
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-1438
Mailing Address - Country:US
Mailing Address - Phone:608-847-5100
Mailing Address - Fax:608-847-5110
Practice Address - Street 1:610 MCEVOY ST
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1438
Practice Address - Country:US
Practice Address - Phone:608-847-5100
Practice Address - Fax:608-847-5110
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2621-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant