Provider Demographics
NPI:1992944300
Name:PROVO, BARBARA J (APNP)
Entity type:Individual
Prefix:MS
First Name:BARBARA
Middle Name:J
Last Name:PROVO
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:MS
Other - First Name:BARBARA
Other - Middle Name:J
Other - Last Name:GOEDDERZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:VASCULAR SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3902
Mailing Address - Fax:414-805-8514
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:VASCULAR SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3902
Practice Address - Fax:414-805-8514
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1992944300Medicaid
WI736011375Medicare PIN