Healthcare Provider Details

I. General information

NPI: 1275114712
Provider Name (Legal Business Name): MR. MICHAEL ANDREW CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 S LEE ST
APPLETON WI
54915-4261
US

IV. Provider business mailing address

1828 S LEE ST
APPLETON WI
54915-4261
US

V. Phone/Fax

Practice location:
  • Phone: 563-505-9271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF04210292
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: