Healthcare Provider Details

I. General information

NPI: 1013986652
Provider Name (Legal Business Name): STEPHEN HANISEE PARK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

S7208A YANSKE ROAD
VIROQUA WI
54665-5466
US

IV. Provider business mailing address

S7208A YANSKE ROAD
VIROQUA WI
54665-5466
US

V. Phone/Fax

Practice location:
  • Phone: 608-675-3848
  • Fax:
Mailing address:
  • Phone: 608-675-3848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: