Active NPI
Kheson Kaballa Madison
- Physical Therapy Assistant
- Wisconsin Rapids, WI
National Provider Identifier
1558871525
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 2403-19
- Practice address
- 555 W Grand Ave
Wisconsin Rapids, WI 54495-2784 - Phone
- (715) 424-4682
- Fax
- (715) 424-4614
- NPI assigned
- Oct 4, 2017
- 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 Therapy Assistant | 225200000X | 2403-19 | WI | Primary |
Addresses
Primary practice location
555 W Grand Ave
Wisconsin Rapids, WI 54495-2784
Mailing address
555 W Grand Ave
Wisconsin Rapids, WI 54495-2784
Phone (715) 424-4682
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)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2403-19 | WI | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1507075200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1507075200000",
"number": "1558871525",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "555 W GRAND AVE",
"city": "WISCONSIN RAPIDS",
"state": "WI",
"postal_code": "544952784",
"telephone_number": "715-424-4682",
"fax_number": "715-424-4614"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "555 W GRAND AVE",
"city": "WISCONSIN RAPIDS",
"state": "WI",
"postal_code": "544952784",
"telephone_number": "715-424-4682",
"fax_number": "715-424-4614"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MADISON",
"first_name": "KHESON",
"middle_name": "KABALLA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2017-10-04",
"last_updated": "2017-10-04",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "WI",
"license": "2403-19",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Wisconsin Rapids, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.