Healthcare Provider Details

I. General information

NPI: 1255390209
Provider Name (Legal Business Name): ANTOINETTE GONZAGA HAYEK M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANTOINETTE GONZAGA M.D.

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 PLAZA DR
WAUSAU WI
54401-4129
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 715-847-3000
  • Fax:
Mailing address:
  • Phone: 715-847-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number20080309
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62545
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: