Provider Demographics
NPI:1962414938
Name:WISHAU, JAMES P (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:WISHAU
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 E TYRANENA PARK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-9678
Mailing Address - Country:US
Mailing Address - Phone:920-648-8393
Mailing Address - Fax:920-648-3656
Practice Address - Street 1:200 E TYRANENA PARK RD
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-9678
Practice Address - Country:US
Practice Address - Phone:920-648-8393
Practice Address - Fax:920-648-3656
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI24282207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIBW0648812OtherDEA
WIBW0648812OtherDEA
B57679Medicare UPIN