Healthcare Provider Details

I. General information

NPI: 1245335868
Provider Name (Legal Business Name): MARY LAAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 N. 76TH STREET
MILWAUKEE WI
53223
US

IV. Provider business mailing address

8901 N. 76TH STREET
MILWAUKEE WI
53223
US

V. Phone/Fax

Practice location:
  • Phone: 414-354-0772
  • Fax: 414-365-0773
Mailing address:
  • Phone: 414-354-0772
  • Fax: 414-365-0773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number229-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: