Provider Demographics
NPI:1710975065
Name:MOUREAU, TIMOTHY A (APNP CDE)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:A
Last Name:MOUREAU
Suffix:
Gender:M
Credentials:APNP CDE
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 365
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:WI
Mailing Address - Zip Code:54155-0365
Mailing Address - Country:US
Mailing Address - Phone:920-869-2711
Mailing Address - Fax:
Practice Address - Street 1:525 AIRPORT DR
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:WI
Practice Address - Zip Code:54155-9035
Practice Address - Country:US
Practice Address - Phone:920-869-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI91719163W00000X
WI446363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI500001880OtherRAILROAD MEDICARE
WI43838600Medicaid
WI43838600Medicaid
WIS77266Medicare UPIN
WI003107270Medicare ID - Type Unspecified