Provider Demographics
NPI:1588770333
Name:LAST, MICHAEL A (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:LAST
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:2664 S ONEIDA ST STE 102
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5615
Practice Address - Country:US
Practice Address - Phone:920-321-5700
Practice Address - Fax:920-888-4283
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9573-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI650025192OtherRAILROAD MEDICARE
WI40345700Medicaid
WI650024852OtherRAILROAD MEDICARE
WI000786035OtherMEDICARE
WI650024852OtherRAILROAD MEDICARE
WI650025192OtherRAILROAD MEDICARE