Provider Demographics
NPI:1528006863
Name:TOLAT, HOLLEY WILLENBERG (DPM)
Entity type:Individual
Prefix:
First Name:HOLLEY
Middle Name:WILLENBERG
Last Name:TOLAT
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:HOLLEY
Other - Middle Name:J
Other - Last Name:WILLENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W231N1440 CORPORATE CT
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1303
Mailing Address - Country:US
Mailing Address - Phone:262-896-6000
Mailing Address - Fax:
Practice Address - Street 1:W231N1440 CORPORATE CT
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1303
Practice Address - Country:US
Practice Address - Phone:262-896-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI909213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43241100Medicaid
WI0910Medicare ID - Type Unspecified
WI43241100Medicaid