Provider Demographics
NPI:1558326967
Name:MARA, TRUDY A (APNP)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:A
Last Name:MARA
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 TUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-3319
Mailing Address - Country:US
Mailing Address - Phone:608-356-2145
Mailing Address - Fax:608-356-2147
Practice Address - Street 1:1700 TUTTLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-3319
Practice Address - Country:US
Practice Address - Phone:608-356-2145
Practice Address - Fax:608-356-2147
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI994363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1558326967Medicaid
WI1558326967Medicaid
WI500020455Medicare PIN
WI1037831OtherPHYSICIANS PLUS
WI009113215Medicare PIN
WI004657155Medicare PIN
WI500021656Medicare PIN