Provider Demographics
NPI:1104811793
Name:FUSS, MARK A (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:FUSS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:575 4TH ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1785
Practice Address - Country:US
Practice Address - Phone:920-388-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI374-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42910400Medicaid
WI000633000Medicare Oscar/Certification
WIK400224771Medicare Oscar/Certification
WI970004673Medicare Oscar/Certification
WIR97720Medicare UPIN
WIK400100185Medicare Oscar/Certification