MEDICARE: MATTHEW J VARNUM LPN

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	164W00000X	Licensed Practical Nurse	315136-31	WI

General Provider Information

NPI Number	:	1962775866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW J VARNUM LPN

Provider Business Mailing Address
First Line	:	2796 PLANTATION ROAD
Second Line	:
City	:	PELICAN LAKE
State	:	WI
Zip	:	54463-9501
Country	:	US
Telephone Number	:	715-360-1585
Fax Number	:

Provider Business Practice Location Address
First Line	:	2796 PLANTATION ROAD
Second Line	:
City	:	PELICAN LAKE
State	:	WI
Zip	:	54463-9501
Country	:	US
Telephone Number	:	715-360-1585
Fax Number	:

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

Provider Enumeration Date	:	02/23/2012
Last Update Date	:	02/23/2012

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