Provider Demographics
NPI:1134116890
Name:GARNAAS, MARK T (PA C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:GARNAAS
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:CARDIOTHORACIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-6900
Mailing Address - Fax:414-955-6204
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:CARDIOTHORACIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-6900
Practice Address - Fax:414-955-6204
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1134116890Medicaid
WI42902800Medicaid
R97845Medicare UPIN
WI42902800Medicaid
WI048671018Medicare PIN