Healthcare Provider Details

I. General information

NPI: 1598039943
Provider Name (Legal Business Name): SCOTT MICHAEL PETHAN MS, BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W 9TH AVE SUITE 107
OSHKOSH WI
54904-7247
US

IV. Provider business mailing address

2700 W 9TH AVE SUITE 107
OSHKOSH WI
54904-7247
US

V. Phone/Fax

Practice location:
  • Phone: 920-236-1835
  • Fax: 920-223-1182
Mailing address:
  • Phone: 920-236-1835
  • Fax: 920-223-1182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number136064-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: