Provider Demographics
NPI:1215028170
Name:VAD, MICHAEL D (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:VAD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S KNOWLES AVE
Mailing Address - Street 2:PO BOX 118
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-0118
Mailing Address - Country:US
Mailing Address - Phone:715-246-3018
Mailing Address - Fax:715-246-3019
Practice Address - Street 1:130 S KNOWLES AVE
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1727
Practice Address - Country:US
Practice Address - Phone:715-246-3018
Practice Address - Fax:715-246-3019
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-158100-7367500000X
MN76740367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN097N8VAOtherBLUE CROSS BLUE SHIELD
MN929483000Medicaid
MN097N8VAOtherBLUE CROSS BLUE SHIELD