Provider Demographics
NPI:1770857229
Name:MCNIESH, TODD L (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:L
Last Name:MCNIESH
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-454-4101
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:2500 E CAPITOL DR STE 1200
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8735
Practice Address - Country:US
Practice Address - Phone:920-830-6877
Practice Address - Fax:999-999-9999
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADOOMedicare UPIN