Provider Demographics
NPI:1386683563
Name:GOSPODAREK, MARY P (APNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:P
Last Name:GOSPODAREK
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:P
Other - Last Name:SHIMEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2219 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-2416
Mailing Address - Country:US
Mailing Address - Phone:920-793-2281
Mailing Address - Fax:
Practice Address - Street 1:2219 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241
Practice Address - Country:US
Practice Address - Phone:920-793-2281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1539363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43904900Medicaid
S93373Medicare UPIN