Healthcare Provider Details

I. General information

NPI: 1396776589
Provider Name (Legal Business Name): ROGER A HANDTKE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ESSENTIA HEALTH SPOONER CLINIC 1180 CHANDLER DRIVE
SPOONER WI
54801
US

IV. Provider business mailing address

13380 W TREPANIA RD
HAYWARD WI
54843-2186
US

V. Phone/Fax

Practice location:
  • Phone: 715-635-2151
  • Fax:
Mailing address:
  • Phone: 715-638-5100
  • Fax: 715-634-6107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02001222A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number63316
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: