Provider Demographics
NPI:1902006059
Name:PANTZLAFF, DANIEL (HIS)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:PANTZLAFF
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2733 MANITOWOC RD STE 8B
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4901
Mailing Address - Country:US
Mailing Address - Phone:920-468-7474
Mailing Address - Fax:
Practice Address - Street 1:2733 MANITOWOC RD STE 8B
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4901
Practice Address - Country:US
Practice Address - Phone:920-468-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1239-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42837600Medicaid