Basic Information
Provider Information | |||||||||
NPI: | 1962772632 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOLTER | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 87475 COUNTY HIGHWAY C | ||||||||
Address2: |   | ||||||||
City: | CORNUCOPIA | ||||||||
State: | WI | ||||||||
PostalCode: | 548274731 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156855400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1635 MAPLE LN | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | WI | ||||||||
PostalCode: | 548063610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156855400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2012 | ||||||||
LastUpdateDate: | 01/11/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 173812-030 | WI | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.