Provider Demographics
NPI:1720594104
Name:STAUBACH, ZANE
Entity Type:Individual
Prefix:
First Name:ZANE
Middle Name:
Last Name:STAUBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2409
Mailing Address - Country:US
Mailing Address - Phone:414-328-7950
Mailing Address - Fax:414-328-8505
Practice Address - Street 1:8901 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2409
Practice Address - Country:US
Practice Address - Phone:414-328-7950
Practice Address - Fax:414-328-8505
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0005888207ZP0101X
WI73434-20207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI73434-20OtherMEDICAL LICENSE