Provider Demographics
NPI:1639163652
Name:ARIZOLA, MICHAEL D III (PAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:ARIZOLA
Suffix:III
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1305
Mailing Address - Country:US
Mailing Address - Phone:920-730-6700
Mailing Address - Fax:
Practice Address - Street 1:1506 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915
Practice Address - Country:US
Practice Address - Phone:920-730-7690
Practice Address - Fax:920-730-2655
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41964900Medicaid
WI41964900Medicaid
P76927Medicare UPIN
WI045345300Medicare ID - Type Unspecified