Provider Demographics
NPI:1164630653
Name:MIER, RANDALL J
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:MIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W152 N6861 WESTWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-5045
Mailing Address - Country:US
Mailing Address - Phone:414-479-9400
Mailing Address - Fax:414-259-1663
Practice Address - Street 1:1000 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3533
Practice Address - Country:US
Practice Address - Phone:414-479-9400
Practice Address - Fax:414-259-1663
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIM600-7305-9214-06172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIDRR 18824OtherPUBLIC PASSENGERS LICENSE