Basic Information
| Provider Information | |||||||||
| NPI: | 1679849111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAEL | ||||||||
| FirstName: | JESSIKA | ||||||||
| MiddleName: | DIAZ | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIAZ LARA | ||||||||
| OtherFirstName: | JESSIKA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 202 S PARK ST | ||||||||
| Address2: | 4 TOWER | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147490907 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 202 S PARK ST | ||||||||
| Address2: | UNITY POINT MERITER 4 TOWER | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084176676 | ||||||||
| FaxNumber: | 6084175746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 06/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A135774 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 70495 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.