Healthcare Provider Details

I. General information

NPI: 1134863228
Provider Name (Legal Business Name): CONNOR SCHMIDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date: 06/21/2022
Reactivation Date: 07/19/2022

III. Provider practice location address

1280 CHANDLER DR
SPOONER WI
54801-2202
US

IV. Provider business mailing address

1311 GRANT ST
SPOONER WI
54801-1751
US

V. Phone/Fax

Practice location:
  • Phone: 715-635-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number199795
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number12024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: