Basic Information
| Provider Information | |||||||||
| NPI: | 1518928993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WASSENAAR | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 AMERICAN AVE STE 108 | ||||||||
| Address2: | PROHEALTH CARE REGIONAL CANCER CENTER | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531885071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282570 | ||||||||
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| Practice Location | |||||||||
| Address1: | 721 AMERICAN AVE STE 108 | ||||||||
| Address2: | PROHEALTH CARE REGIONAL CANCER CENTER | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531885071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282570 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 04/23/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 46327 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 46327 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 34691700 | 05 | WI | MEDICAID |