Provider Demographics
NPI:1801814967
Name:VAN PERNIS, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:VAN PERNIS
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 1:1625 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3768
Mailing Address - Country:US
Mailing Address - Phone:715-685-7500
Mailing Address - Fax:715-682-2481
Practice Address - Street 1:1625 MAPLE LN
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3768
Practice Address - Country:US
Practice Address - Phone:715-685-7500
Practice Address - Fax:715-682-2481
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21536-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN150257300Medicaid
WI30197300Medicaid
WI30197300Medicaid
B57282Medicare UPIN