Basic Information
| Provider Information | |||||||||
| NPI: | 1235303967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANKUMAH-SAIKOOM | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 TUTTLE ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539133319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083553800 | ||||||||
| FaxNumber: | 6083557001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 TUTTLE ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539133319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083553800 | ||||||||
| FaxNumber: | 6083557001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2008 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 53876-020 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1235303967 | 05 | WI | MEDICAID |