Basic Information
| Provider Information | |||||||||
| NPI: | 1508811159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKKELSON | ||||||||
| FirstName: | WENDY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 W KINNICKINNIC RIVER PKWY | ||||||||
| Address2: | SUITE 165 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143852301 | ||||||||
| FaxNumber: | 4143858791 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 W KINNICKINNIC RIVER PKWY | ||||||||
| Address2: | SUITE 165 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143852301 | ||||||||
| FaxNumber: | 4143858791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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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 | 208600000X | 25658-020 | WI | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020050375 | 01 | WI | RAILROAD MEDICARE | OTHER | 30582600 | 05 | WI | MEDICAID |