Basic Information
| Provider Information | |||||||||
| NPI: | 1013936731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAKEFIELD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BRADLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 TOWER AVE | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548805337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153921955 | ||||||||
| FaxNumber: | 7153921935 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 TOWER AVE | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548805337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153921955 | ||||||||
| FaxNumber: | 7153921935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 08/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R 152778-6 | MN | Y | Nursing Service Providers | Registered Nurse | 163W00000X | 138615-30 | WI | N | Nursing Service Providers | Registered Nurse |
No ID Information.