Provider Demographics
NPI:1386810695
Name:PODEWILS, LISA A (PTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:PODEWILS
Suffix:
Gender:F
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:N87W17309 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2760
Mailing Address - Country:US
Mailing Address - Phone:262-257-4740
Mailing Address - Fax:
Practice Address - Street 1:N87W17309 MAIN ST
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2760
Practice Address - Country:US
Practice Address - Phone:262-257-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40356600Medicaid