Healthcare Provider Details

I. General information

NPI: 1366043051
Provider Name (Legal Business Name): GARY D. HOMEIER AG-APNP-BC PMC-ED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2020
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 75TH ST
KENOSHA WI
53142-7884
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-948-5600
  • Fax: 262-948-5735
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number11740-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11740
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: