Provider Demographics
NPI:1871873620
Name:WEIS, KRISTINA MAE (PTA)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MAE
Last Name:WEIS
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 1:631 ASCOT ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51103-3191
Mailing Address - Country:US
Mailing Address - Phone:712-560-6447
Mailing Address - Fax:
Practice Address - Street 1:3501 DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3641
Practice Address - Country:US
Practice Address - Phone:402-494-3440
Practice Address - Fax:402-494-3441
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE989225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant