Healthcare Provider Details

I. General information

NPI: 1760365787
Provider Name (Legal Business Name): MITCHELL COLE VARGOVICH APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 MEMORIAL DR
CHILTON WI
53014-1568
US

IV. Provider business mailing address

4351 W COLLEGE AVE STE 130
APPLETON WI
54914-3970
US

V. Phone/Fax

Practice location:
  • Phone: 920-849-2386
  • Fax:
Mailing address:
  • Phone: 920-630-1569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1709133
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: