Basic Information
| Provider Information | |||||||||
| NPI: | 1568446128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIQUELME | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960 | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983370212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603773776 | ||||||||
| FaxNumber: | 3603732096 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 WEST BROWN ST | ||||||||
| Address2: | |||||||||
| City: | WAUPUN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539631702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203246801 | ||||||||
| FaxNumber: | 3603732096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36042-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD60319995 | 01 | WA | LICENSE | OTHER | 36042 | 01 | WI | LICENSE | OTHER | 32097700 | 05 | WI | MEDICAID |