Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 26967 | WI |
Y | 111NI0900X | Internist | 26967 | WI |
N | 207RG0300X | Geriatric Medicine | 26967 | WI |
NPI | 1104927896 |
---|---|
Provider Name | Richard F Fossen |
First Address | Marshfield, WI 54449-5703 |
Second Address | Minocqua, WI 54548-1390 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2006 |
Last Update Date | 31/05/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
APPR | (05) | WI |
B52859 | (02) |