Provider Demographics
NPI:1013096262
Name:AREGBESOLA, MARTHA T (NP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:T
Last Name:AREGBESOLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9969 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9533
Mailing Address - Country:US
Mailing Address - Phone:414-325-4710
Mailing Address - Fax:
Practice Address - Street 1:10101 S 27TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-7209
Practice Address - Country:US
Practice Address - Phone:414-325-4704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2997-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI148862OtherRN LICENSE
WI36020300Medicaid
WI2997-033OtherAPNP
WI148862OtherRN LICENSE