Healthcare Provider Details

I. General information

NPI: 1972836633
Provider Name (Legal Business Name): MARK ANDREW FERGUS APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 REDBIRD CIR STE 300
DE PERE WI
54115-7980
US

IV. Provider business mailing address

323 S 18TH AVE
STURGEON BAY WI
54235-1401
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-6870
  • Fax: 920-338-6829
Mailing address:
  • Phone: 920-746-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3840-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number138144
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: