Basic Information
| Provider Information | |||||||||
| NPI: | 1104811793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUSS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 4TH ST | ||||||||
| Address2: | |||||||||
| City: | KEWAUNEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542161785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203884640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 374-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42910400 | 05 | WI | MEDICAID |