Provider Demographics
NPI:1578885323
Name:NTABA, MERVIN K
Entity Type:Individual
Prefix:MR
First Name:MERVIN
Middle Name:K
Last Name:NTABA
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 1:5211 N MOHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5022
Mailing Address - Country:US
Mailing Address - Phone:414-405-3133
Mailing Address - Fax:
Practice Address - Street 1:5211 N MOHAWK AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5022
Practice Address - Country:US
Practice Address - Phone:414-405-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI309706-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse