Provider Demographics
NPI:1578548947
Name:DEHNEL, MARK JOHN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:DEHNEL
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:595 COUNTY ROAD R
Practice Address - Street 2:
Practice Address - City:DENMARK
Practice Address - State:WI
Practice Address - Zip Code:54208-9529
Practice Address - Country:US
Practice Address - Phone:920-863-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI991363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV991-023OtherLICENSE
WI000016Medicare Oscar/Certification
WI000029Medicare Oscar/Certification
WIWI1119007Medicare Oscar/Certification
WV991-023OtherLICENSE
WI001607310Medicare Oscar/Certification
WI013400215Medicare Oscar/Certification
WI000055Medicare Oscar/Certification
WI000007Medicare Oscar/Certification
WI802100041Medicare Oscar/Certification
WI000012Medicare Oscar/Certification
WI000134Medicare Oscar/Certification
WI000017Medicare Oscar/Certification
WI000020Medicare Oscar/Certification