Provider Demographics
NPI:1619032919
Name:DEPEW, MICHAEL R (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:DEPEW
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 S. 41ST ST.
Mailing Address - Street 2:LAKESHORE ORTHOPEDICS
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220
Mailing Address - Country:US
Mailing Address - Phone:920-682-5233
Mailing Address - Fax:
Practice Address - Street 1:1650 S. 41ST ST.
Practice Address - Street 2:LAKESHORE ORTHOPEDICS
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220
Practice Address - Country:US
Practice Address - Phone:920-682-5233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1419363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41956200Medicaid
WI0083Medicare ID - Type Unspecified
WIS87449Medicare UPIN