Basic Information
| Provider Information | |||||||||
| NPI: | 1538152053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGG | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1687 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540221571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154256701 | ||||||||
| FaxNumber: | 7154257075 | ||||||||
| Practice Location | |||||||||
| Address1: | 1687 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540221571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154256701 | ||||||||
| FaxNumber: | 7154257075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 02/09/2010 | ||||||||
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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 | 363A00000X | 1032 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 41928200 | 05 | WI | MEDICAID |