Healthcare Provider Details

I. General information

NPI: 1033009493
Provider Name (Legal Business Name): GREGORY WUNROW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N112W15415 MEQUON RD
GERMANTOWN WI
53022-3410
US

IV. Provider business mailing address

205 W SAINT PAUL AVE APT 105
WAUKESHA WI
53188-5163
US

V. Phone/Fax

Practice location:
  • Phone: 262-250-7800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number404719
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: