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General NPI Number Information
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NPI Number | 1295739225
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Entity Type | Individual
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Provider Name | JUAN SEBASTIAN PRECIADO-RIESTRA MD
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Gender | Male
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Dates
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Enumeration Date | 06/08/2005
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Last Update Date | 04/29/2016
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Provider Practice Location Address
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Address Line | 400 S TOWNLINE RD
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City | WAUTOMA
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State | WI
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Zip | 54982-6922
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Country | US
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Telephone | 920-787-4737
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Fax |
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Provider Business Mailing Address
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Address Line | 933 BUFFALO RIDGE LN
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City | WAUPACA
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State | WI
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Zip | 54981-8192
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Country | US
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Telephone | 715-252-2899
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 46438-020
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License Number State | WI
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