Basic Information
| Provider Information | |||||||||
| NPI: | 1598705295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAU | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548480470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153568000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 240 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153568000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 22073-020 | WI | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 32315600 | 05 | WI | MEDICAID |