Healthcare Provider Details

I. General information

NPI: 1861715468
Provider Name (Legal Business Name): MARK OLIVER PEASE APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 12/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W4051 HWY NN
ELKHORN WI
53121-4338
US

IV. Provider business mailing address

5705 W OPEN MDW
MC FARLAND WI
53558-8804
US

V. Phone/Fax

Practice location:
  • Phone: 262-741-3200
  • Fax: 262-741-3217
Mailing address:
  • Phone: 608-838-2075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number392-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number392-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number68680-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: