Provider Demographics
NPI:1720073208
Name:HOMBURG, NANCY JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:JEAN
Last Name:HOMBURG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3329 N RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911
Mailing Address - Country:US
Mailing Address - Phone:920-380-2719
Mailing Address - Fax:920-380-2755
Practice Address - Street 1:3329 N RICHMOND ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911
Practice Address - Country:US
Practice Address - Phone:920-380-2719
Practice Address - Fax:920-380-2755
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AH6655370OtherBNDD
WI30158000Medicaid
WI002945300Medicare ID - Type Unspecified
AH6655370OtherBNDD
B53682Medicare UPIN
WI30158000Medicaid