Basic Information
Provider Information | |||||||||
NPI: | 1487093241 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLOOD | ||||||||
FirstName: | DENNIS | ||||||||
MiddleName: | CHARLES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 704 PINE PL | ||||||||
Address2: |   | ||||||||
City: | RICE LAKE | ||||||||
State: | WI | ||||||||
PostalCode: | 548682378 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5078849118 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1700 W STOUT ST | ||||||||
Address2: |   | ||||||||
City: | RICE LAKE | ||||||||
State: | WI | ||||||||
PostalCode: | 548685000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152341515 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2013 | ||||||||
LastUpdateDate: | 04/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 3155-23 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.