Basic Information
| Provider Information | |||||||||
| NPI: | 1699118174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARRIEUX | ||||||||
| FirstName: | GREGORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
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| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148058632 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2013 | ||||||||
| LastUpdateDate: | 07/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204F00000X | MD2021-0736 | NM | Y | Allopathic & Osteopathic Physicians | Transplant Surgery | 208600000X | 65599 | MN | N | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.