MEDICARE: MARK NORMAN MOLDENHAUER RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	161951-30	WI

General Provider Information

NPI Number	:	1447716576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK NORMAN MOLDENHAUER RN

Provider Business Mailing Address
First Line	:	N6260 COLWELL RD
Second Line	:
City	:	TAYLOR
State	:	WI
Zip	:	54659-6204
Country	:	US
Telephone Number	:	715-662-2062
Fax Number	:	715-662-2062

Provider Business Practice Location Address
First Line	:	N6260 COLWELL RD
Second Line	:
City	:	TAYLOR
State	:	WI
Zip	:	54659-6204
Country	:	US
Telephone Number	:	715-662-2062
Fax Number	:	715-662-2062

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2019
Last Update Date	:	03/07/2019

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