Basic Information
| Provider Information | |||||||||
| NPI: | 1205051141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EXTEN | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 335 GLESSNER AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084176000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6408 COPPS AVE | ||||||||
| Address2: | |||||||||
| City: | MONONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537163702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084173000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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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 | 207X00000X | 35.129789 | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 52635 | WI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1205051141 | 05 | WI | MEDICAID |