Provider Demographics
NPI:1265924161
Name:GWARO, JEREMIAH MOBISA (APNP)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:MOBISA
Last Name:GWARO
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 LONDON ST
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1933
Mailing Address - Country:US
Mailing Address - Phone:651-503-7412
Mailing Address - Fax:
Practice Address - Street 1:1505 NORTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985
Practice Address - Country:US
Practice Address - Phone:920-426-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8323-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily