Provider Demographics
NPI:1588235105
Name:VAN VUUREN, FREDERICK JACOBUS
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JACOBUS
Last Name:VAN VUUREN
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 1:2500 W MANGOLD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-4965
Mailing Address - Country:US
Mailing Address - Phone:262-777-0798
Mailing Address - Fax:
Practice Address - Street 1:377 W RIVER WOODS PKWY STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1088
Practice Address - Country:US
Practice Address - Phone:414-323-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10598OtherNP LICENSE