Provider Demographics
NPI:1124101886
Name:PRYOR, JON L (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:L
Last Name:PRYOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF UROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-0805
Mailing Address - Fax:414-805-0771
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF UROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-0805
Practice Address - Fax:414-805-0771
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN34340208800000X
WI54002208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN19-00018OtherMEDICA PRIMARY
MN148007300Medicaid
MN2T448PROtherBLUE CROSS BLUE SHIELD
MN0255504OtherPREFERRED ONE
MN19-00606OtherMEDICA CHOICE
WI1124101886Medicaid
MN603764OtherARAZ
MN101399OtherUCARE
IA0988162Medicaid
MNHP14204OtherHEALTH PARTNERS
MN0255504OtherPREFERRED ONE
MN19-00018OtherMEDICA PRIMARY
340007721Medicare ID - Type UnspecifiedRAILROAD
MN2T448PROtherBLUE CROSS BLUE SHIELD