Basic Information
Provider Information | |||||||||
NPI: | 1134311541 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOMMER | ||||||||
FirstName: | AANDERS | ||||||||
MiddleName: | JARL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1615 MAPLE LANE | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | WI | ||||||||
PostalCode: | 54806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7158385222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1615 MAPLE LANE | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | WI | ||||||||
PostalCode: | 54806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156855500 | ||||||||
FaxNumber: | 7156824022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2007 | ||||||||
LastUpdateDate: | 05/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 50811 | MN | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 54943 | WI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.