Provider Demographics
NPI:1316934250
Name:MITTELSTAEDT, PHILIP J (CRNA)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:J
Last Name:MITTELSTAEDT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:845 PARKSIDE ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-8505
Practice Address - Country:US
Practice Address - Phone:920-748-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77170-030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43303800Medicaid
WI43303800Medicaid
WI000021415Medicare ID - Type Unspecified