Healthcare Provider Details

I. General information

NPI: 1881646347
Provider Name (Legal Business Name): JAY E FOTLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 KWIK TRIP WAY
LA CROSSE WI
54602
US

IV. Provider business mailing address

2222 KWIK TRIP WAY
LA CROSSE WI
54602
US

V. Phone/Fax

Practice location:
  • Phone: 608-780-2269
  • Fax:
Mailing address:
  • Phone: 608-780-2269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR-100621-0
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4372-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: