Provider Demographics
NPI:1821160763
Name:TANEL, GWENDOLYN A (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:A
Last Name:TANEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-389-2338
Mailing Address - Fax:414-385-8987
Practice Address - Street 1:120 CHAPMAN FARMS BLVD
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-9337
Practice Address - Country:US
Practice Address - Phone:262-363-6160
Practice Address - Fax:262-363-6165
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
68375Medicare PIN
B57048Medicare UPIN
000468575Medicare ID - Type Unspecified