Provider Demographics
NPI:1659333201
Name:LANDGRAF, MICHAEL G (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:LANDGRAF
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PARK STREET
Mailing Address - Street 2:STE #360
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715
Mailing Address - Country:US
Mailing Address - Phone:608-257-2208
Mailing Address - Fax:
Practice Address - Street 1:20 PARK STREET
Practice Address - Street 2:STE #360
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715
Practice Address - Country:US
Practice Address - Phone:608-257-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI231-33367H00000X
WI91549-30367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659333201Medicaid
WI3091OtherDEAN HEALTH INSURANCE
WI43329400Medicaid
WI3091OtherDEAN HEALTH INSURANCE
WI103074150Medicare PIN