Provider Demographics
NPI:1568480614
Name:VAN ETTEN, MARK AEPPLI
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:AEPPLI
Last Name:VAN ETTEN
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 1:707 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-1234
Mailing Address - Country:US
Mailing Address - Phone:715-635-2151
Mailing Address - Fax:715-635-8768
Practice Address - Street 1:707 ASH ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1234
Practice Address - Country:US
Practice Address - Phone:715-635-2151
Practice Address - Fax:715-635-8768
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25178-020207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30518900Medicaid
B57299Medicare UPIN
WI000366003Medicare PIN