1154476141 NPI number — MR. WADE CHRISTIAN PEITERSEN LAT

Table of content: MR. WADE CHRISTIAN PEITERSEN LAT (NPI 1154476141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154476141 NPI number — MR. WADE CHRISTIAN PEITERSEN LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEITERSEN
Provider First Name:
WADE
Provider Middle Name:
CHRISTIAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LAT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154476141
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 ALGOMA BLVD
Provider Second Line Business Mailing Address:
KOLF SPORTS CENTER 169L
Provider Business Mailing Address City Name:
OSHKOSH
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54901-3551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-424-7138
Provider Business Mailing Address Fax Number:
920-424-1068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 ALGOMA BLVD
Provider Second Line Business Practice Location Address:
KOLF SPORTS CENTER 169L
Provider Business Practice Location Address City Name:
OSHKOSH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54901-3551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-424-7138
Provider Business Practice Location Address Fax Number:
920-424-1068
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  125-039 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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