Provider Demographics
NPI:1194030981
Name:WEIDEMANN, MARK T (APNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:WEIDEMANN
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N WESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7668
Mailing Address - Country:US
Mailing Address - Phone:920-303-8700
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7668
Practice Address - Country:US
Practice Address - Phone:920-303-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4130363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner