Healthcare Provider Details

I. General information

NPI: 1255914735
Provider Name (Legal Business Name): MARK GAROLD PONTOW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S ONEIDA ST
APPLETON WI
54915-1305
US

IV. Provider business mailing address

1506 S ONEIDA ST
APPLETON WI
54915-1305
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-2000
  • Fax:
Mailing address:
  • Phone: 920-738-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11943-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: