Basic Information
| Provider Information | |||||||||
| NPI: | 1700877875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PREVOST | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 S 24TH AVE | ||||||||
| Address2: | PMB384 | ||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152167795 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 61797-20 | WI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.