Provider Demographics
NPI:1154349090
Name:FANTAZZI, FRANK C (PT DPT)
Entity type:Individual
Prefix:
First Name:FRANK
Middle Name:C
Last Name:FANTAZZI
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 S GREEN BAY RD
Mailing Address - Street 2:STE 200
Mailing Address - City:MT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4410
Mailing Address - Country:US
Mailing Address - Phone:262-321-0240
Mailing Address - Fax:262-321-0242
Practice Address - Street 1:1532 S GREEN BAY RD STE 200
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4410
Practice Address - Country:US
Practice Address - Phone:262-321-0240
Practice Address - Fax:262-321-0242
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1770-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40039400Medicaid
WI000081050/0002Medicare ID - Type Unspecified