Basic Information
| Provider Information | |||||||||
| NPI: | 1760982763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUELLER | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | W129N7055 NORTHFIELD DR | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530510538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622535400 | ||||||||
| FaxNumber: | 2622533399 | ||||||||
| Practice Location | |||||||||
| Address1: | W129N7055 NORTHFIELD DR | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530510538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622535400 | ||||||||
| FaxNumber: | 2622533399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2018 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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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 | 363L00000X | 8156-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1760982763 | 05 | WI | MEDICAID | 2017024582 | 01 | ANCC CERTIFICATION | OTHER | 8156-33 | 01 | WI | ADVANCED PRACTICE NURSE PRESCRIBER | OTHER |