Healthcare Provider Details

I. General information

NPI: 1851351654
Provider Name (Legal Business Name): TIM M NORDWIG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 LABAREE ST
WATERTOWN WI
53098-3019
US

IV. Provider business mailing address

609 LABAREE ST
WATERTOWN WI
53098-3019
US

V. Phone/Fax

Practice location:
  • Phone: 920-262-9499
  • Fax:
Mailing address:
  • Phone: 920-262-9499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number60954
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: