Active NPI
Gerald Maryanov, DPT
- Physical Therapist
- Pleasant Prairie, WI
National Provider Identifier
1902799919
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 17200-24
- Practice address
- 811 95TH St
Pleasant Prairie, WI 53158-4913 - Phone
- (262) 344-5316
- NPI assigned
- May 29, 2025
- Last updated
- May 29, 2025
- 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 | 17200-24 | WI | Primary |
Addresses
Primary practice location
811 95TH St
Pleasant Prairie, WI 53158-4913
Mailing address
811 95TH St
Pleasant Prairie, WI 53158-4913
Phone (262) 344-5316
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 |
|---|---|---|---|
| 17200-24 | WI | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1748476800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1748476800000",
"number": "1902799919",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "811 95TH ST",
"city": "PLEASANT PRAIRIE",
"state": "WI",
"postal_code": "531584913",
"telephone_number": "262-344-5316"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "811 95TH ST",
"city": "PLEASANT PRAIRIE",
"state": "WI",
"postal_code": "531584913",
"telephone_number": "262-344-5316"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MARYANOV",
"first_name": "GERALD",
"credential": "DPT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2025-05-29",
"last_updated": "2025-05-29",
"certification_date": "2025-05-29",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "WI",
"license": "17200-24",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Pleasant Prairie, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.