Basic Information
| Provider Information | |||||||||
| NPI: | 1427163500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLOOD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146476326 | ||||||||
| FaxNumber: | 4146718860 | ||||||||
| Practice Location | |||||||||
| Address1: | 2521 S BAY SHORE DR | ||||||||
| Address2: | |||||||||
| City: | SISTER BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208542347 | ||||||||
| FaxNumber: | 9208544708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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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 | 20-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | 60716-030 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 41257600 | 05 | WI | MEDICAID |