1235579053 NPI number — MICHELLE R WEGNER PC

Table of content: MICHELLE R WEGNER PC (NPI 1235579053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235579053 NPI number — MICHELLE R WEGNER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEGNER
Provider First Name:
MICHELLE
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PC
Provider Gender Code:
F

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:
1235579053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
631 FOREST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUSAU
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54403-5524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-842-0944
Provider Business Mailing Address Fax Number:
715-845-6477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1509 N 4TH ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
TOMAHAWK
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54487-2142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-236-3792
Provider Business Practice Location Address Fax Number:
715-845-6477
Provider Enumeration Date:
06/25/2013

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: 101YP2500X , with the licence number:  1497-226 , 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)

  • Identifier: 1235579053 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com