Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 4039 | WI |
Y | 213EG0000X | General Practice | 4039 | WI |
NPI | 1003914607 |
---|---|
Provider Name | Kenneth Paul Ferentchak |
First Address | Wauwatosa, WI 53226-3431 |
Second Address | Wauwatosa, WI 53226-3431 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 08/07/2007 |