Provider Demographics
NPI:1467644195
Name:SWAN, JAMES M JR (APNP)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:M
Last Name:SWAN
Suffix:JR
Gender:M
Credentials:APNP
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Mailing Address - Street 1:2817 NEW PINERY ROAD
Mailing Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0387
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:608-429-3966
Practice Address - Street 1:2817 NEW PINERY ROAD
Practice Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-0387
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:608-429-3966
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2012-01-31
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Provider Licenses
StateLicense IDTaxonomies
WI3155033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36039800Medicaid
WI36039800Medicaid