Provider Demographics
NPI:1164435046
Name:IRMICK, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:IRMICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 OLD ABE RD
Mailing Address - Street 2:
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-9682
Mailing Address - Country:US
Mailing Address - Phone:715-588-3371
Mailing Address - Fax:715-588-7884
Practice Address - Street 1:450 OLD ABE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9682
Practice Address - Country:US
Practice Address - Phone:715-588-3371
Practice Address - Fax:715-588-7884
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2903363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36011200Medicaid
WI001764013Medicare PIN