Active NPI
Anthony Jack Ettmayer Jr., PT
- Physical Therapist
- Port Washington, WI
National Provider Identifier
1457649352
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 11821-024
- Practice address
- 1119 N Wisconsin St
Port Washington, WI 53074-1209 - Phone
- (262) 284-5892
- NPI assigned
- Jul 13, 2011
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 11821-024 | WI | Primary |
Addresses
Primary practice location
1119 N Wisconsin St
Port Washington, WI 53074-1209
Mailing address
1119 N Wisconsin St
Port Washington, WI 53074-1209
Phone (262) 284-5892
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11821-024 | WI | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1310515200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1310515200000",
"number": "1457649352",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1119 N WISCONSIN ST",
"city": "PORT WASHINGTON",
"state": "WI",
"postal_code": "530741209",
"telephone_number": "262-284-5892"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1119 N WISCONSIN ST",
"city": "PORT WASHINGTON",
"state": "WI",
"postal_code": "530741209",
"telephone_number": "262-284-5892"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ETTMAYER",
"first_name": "ANTHONY",
"middle_name": "JACK",
"name_prefix": "Mr.",
"name_suffix": "Jr.",
"credential": "PT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2011-07-13",
"last_updated": "2011-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "WI",
"license": "11821-024",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Port Washington, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.