Healthcare Provider Details

I. General information

NPI: 1114226404
Provider Name (Legal Business Name): AUSTIN GILBERT NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WIND RIDGE DR
WAUSAU WI
54401-4173
US

IV. Provider business mailing address

500 WIND RIDGE DR
WAUSAU WI
54401-4173
US

V. Phone/Fax

Practice location:
  • Phone: 715-847-2611
  • Fax:
Mailing address:
  • Phone: 715-847-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number13255-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number166741
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: