Provider Demographics
NPI:1013090885
Name:MALLON, WILLIAM GUNTHER (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GUNTHER
Last Name:MALLON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 625
Mailing Address - Street 2:
Mailing Address - City:SAINT GERMAIN
Mailing Address - State:WI
Mailing Address - Zip Code:54558-0625
Mailing Address - Country:US
Mailing Address - Phone:715-542-2728
Mailing Address - Fax:
Practice Address - Street 1:2149 FOUND LAKE RD. BOX 625
Practice Address - Street 2:
Practice Address - City:SAINT GERMAIN
Practice Address - State:WI
Practice Address - Zip Code:54558-0625
Practice Address - Country:US
Practice Address - Phone:715-542-2728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI137583-030367500000X
MI470412917367500000X
IN28182298A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000602388OtherANTHEM PROVIDER NUMBER
026511OtherAANA/CRNA
IN200929030Medicaid
IN000000602388OtherANTHEM PROVIDER NUMBER
026511OtherAANA/CRNA