Healthcare Provider Details

I. General information

NPI: 1841307386
Provider Name (Legal Business Name): GRETA M KOSTAC APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRETA MARIE SWANSON

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WISCONSIN AMERICAN DR
FOND DU LAC WI
54935
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 920-907-7000
  • Fax: 920-907-7012
Mailing address:
  • Phone: 414-647-6326
  • Fax: 414-671-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1274-033
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number83758-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: