Healthcare Provider Details

I. General information

NPI: 1407322084
Provider Name (Legal Business Name): MARK WILLIAM DANTUMA APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 E RACINE ST
JANESVILLE WI
53546-2343
US

IV. Provider business mailing address

500 W 190TH ST STE 400
GARDENA CA
90248-4269
US

V. Phone/Fax

Practice location:
  • Phone: 608-371-8000
  • Fax: 608-371-8939
Mailing address:
  • Phone: 714-452-1961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8782-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: