Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036.143132 | IL |
Y | 207QS0010X | Family Doctor - Sports Medicine | 69524-21 | WI |
NPI | 1194137026 |
---|---|
Provider Name | Melissa Faubert |
First Address | Portage, WI 53901-9240 |
Second Address | Portage, WI 53901 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2014 |
Last Update Date | 09/07/2018 |