Healthcare Provider Details

I. General information

NPI: 1457324428
Provider Name (Legal Business Name): MARK E. NORDNESS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MAPLE AVENUE PROHEALTH CARE MEDICAL ASSOCIATES INC.
MUKWONAGO WI
53149
US

IV. Provider business mailing address

N17 W24100 RIVERWOOD DRIVE SUITE 250 PROHEALTH CARE MEDICAL ASSOCIATES INC.
WAUKESHA WI
53149
US

V. Phone/Fax

Practice location:
  • Phone: 262-928-1900
  • Fax: 262-363-1949
Mailing address:
  • Phone: 262-928-4100
  • Fax: 262-928-5835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number41406
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number41406-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: