Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 28 | WI |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 28 | WI |
NPI | 1164415634 |
---|---|
Provider Name | Marcie Ann Janz |
First Address | Fond Du Lac, WI 54935-3748 |
Second Address | Fond Du Lac, WI 54935-3748 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
43817600 | (05) | WI |
S16404 | (02) |