Provider Demographics
NPI:1255403812
Name:STOUT, MICHAEL DAVID (AA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:STOUT
Suffix:
Gender:
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N84W33109 BECKER LN
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-9733
Mailing Address - Country:US
Mailing Address - Phone:561-370-5465
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8700
Practice Address - Fax:414-259-1522
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA900367H00000X
WI74017367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255403812Medicaid