Healthcare Provider Details

I. General information

NPI: 1679760128
Provider Name (Legal Business Name): MICHAEL RICKY BUBACZ MSN, APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 WOLF RD
LAKE TOMAHAWK WI
54539-9487
US

IV. Provider business mailing address

7520 WOLF RD
LAKE TOMAHAWK WI
54539-9487
US

V. Phone/Fax

Practice location:
  • Phone: 715-277-2848
  • Fax:
Mailing address:
  • Phone: 715-277-2848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2806-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: