Provider Demographics
NPI:1639336894
Name:ROURKE, JOHN CHARLES (RN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CHARLES
Last Name:ROURKE
Suffix:
Gender:M
Credentials:RN
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 153
Mailing Address - Street 2:
Mailing Address - City:BLUE MOUNDS
Mailing Address - State:WI
Mailing Address - Zip Code:53517-0153
Mailing Address - Country:US
Mailing Address - Phone:608-437-6167
Mailing Address - Fax:
Practice Address - Street 1:11000 BLISS ST.
Practice Address - Street 2:
Practice Address - City:BLUE MOUNDS
Practice Address - State:WI
Practice Address - Zip Code:53517-0153
Practice Address - Country:US
Practice Address - Phone:608-437-6167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI121292-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38220000Medicaid