Healthcare Provider Details

I. General information

NPI: 1780100586
Provider Name (Legal Business Name): JACOB ADAM TANEL APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 07/21/2022
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KINNICKINNIC RIVER PKWY
MILWAUKEE WI
53215-3669
US

IV. Provider business mailing address

2801 W KINNICKINNIC RIVER PKWY
MILWAUKEE WI
53215-3669
US

V. Phone/Fax

Practice location:
  • Phone: 414-385-1922
  • Fax:
Mailing address:
  • Phone: 414-385-1922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7892
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number7892-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: