Basic Information
| Provider Information | |||||||||
| NPI: | 1386209492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NYQUIST | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WITTROCK | ||||||||
| OtherFirstName: | ALLIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 403 STAGELINE RD | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540167848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155316800 | ||||||||
| FaxNumber: | 7155316801 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 STAGELINE RD | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540167848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155316800 | ||||||||
| FaxNumber: | 7155316801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PENDING | WI | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 1301-25 | WI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.