Basic Information
| Provider Information | |||||||||
| NPI: | 1023182367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANGL | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | RUTH | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRISCH | ||||||||
| OtherFirstName: | HEIDI | ||||||||
| OtherMiddleName: | RUTH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11134 N HWY 77 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156345505 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11134 N HWY 77 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156345505 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 04/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2054 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 43988900 | 05 | WI | MEDICAID |