Provider Demographics
NPI:1215549852
Name:ZONDLO, CARL HENRY
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:HENRY
Last Name:ZONDLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3445 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-8654
Mailing Address - Country:US
Mailing Address - Phone:715-965-3694
Mailing Address - Fax:
Practice Address - Street 1:135 S GIBSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1622
Practice Address - Country:US
Practice Address - Phone:715-748-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WINA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered