Healthcare Provider Details

I. General information

NPI: 1619032919
Provider Name (Legal Business Name): MICHAEL R DEPEW PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 S. 41ST ST. LAKESHORE ORTHOPEDICS
MANITOWOC WI
54220
US

IV. Provider business mailing address

1650 S. 41ST ST. LAKESHORE ORTHOPEDICS
MANITOWOC WI
54220
US

V. Phone/Fax

Practice location:
  • Phone: 920-682-5233
  • Fax:
Mailing address:
  • Phone: 920-682-5233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1419
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier41956200
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: