Basic Information
| Provider Information | |||||||||
| NPI: | 1265737738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SELZER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherCredential: | N.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 E WISCONSIN AVE | ||||||||
| Address2: | SUITE 2000 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532024815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142906720 | ||||||||
| FaxNumber: | 4142906755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177023431 | ||||||||
| FaxNumber: | 8179273603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2011 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209.008335 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | AP125799 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.