=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275400996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY V SIUTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2025
-----------------------------------------------------
Last Update Date | 10/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1315 RICHARDS AVE
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53094-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-262-8838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1315 RICHARDS AVE
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53094-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 10554-40
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------