Provider Demographics
NPI:1508811159
Name:MIKKELSON, WENDY (MD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Mailing Address - Street 2:SUITE 165
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3669
Mailing Address - Country:US
Mailing Address - Phone:414-385-2301
Mailing Address - Fax:414-385-8791
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:SUITE 165
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-385-2301
Practice Address - Fax:414-385-8791
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI25658-020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI020050375OtherRAILROAD MEDICARE
WI30582600Medicaid
B55095Medicare UPIN
WI30582600Medicaid