=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740390822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL L WEIK PAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 04/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 SHERRY AVE
-----------------------------------------------------
City | PARK FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54552-1467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-762-7544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 N OAK AVE
-----------------------------------------------------
City | MARSHFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54449-5777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1575
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------