Provider Demographics
NPI:1881646347
Name:FOTLAND, JAY E
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:E
Last Name:FOTLAND
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 1:2222 KWIK TRIP WAY
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54602
Mailing Address - Country:US
Mailing Address - Phone:608-780-2269
Mailing Address - Fax:
Practice Address - Street 1:2222 KWIK TRIP WAY
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54602
Practice Address - Country:US
Practice Address - Phone:608-780-2269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-100621-0363LA2100X
WI4372-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care