Provider Demographics
NPI:1558624908
Name:LANDIS, MICHAEL T
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:LANDIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-3114
Mailing Address - Country:US
Mailing Address - Phone:715-346-5000
Mailing Address - Fax:
Practice Address - Street 1:900 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-3114
Practice Address - Country:US
Practice Address - Phone:715-346-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD162896367500000X
WI4908367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI188681-30OtherWI STATE LIC RN
WI4908-33OtherAPNP LIC