Provider Demographics
NPI:1396738563
Name:NYWALL, SOREN A (OD)
Entity type:Individual
Prefix:
First Name:SOREN
Middle Name:A
Last Name:NYWALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 PARKWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-5488
Mailing Address - Country:US
Mailing Address - Phone:715-421-2111
Mailing Address - Fax:715-421-2123
Practice Address - Street 1:1220 PARKWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5488
Practice Address - Country:US
Practice Address - Phone:715-421-2111
Practice Address - Fax:715-421-2123
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1687-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T62894Medicare UPIN
000087357Medicare ID - Type Unspecified
WI6199250001Medicare NSC