Provider Demographics
NPI:1861715468
Name:PEASE, MARK OLIVER (APNP)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:OLIVER
Last Name:PEASE
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 W OPEN MDW
Mailing Address - Street 2:
Mailing Address - City:MC FARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558-8804
Mailing Address - Country:US
Mailing Address - Phone:608-838-2075
Mailing Address - Fax:
Practice Address - Street 1:W4051 HWY NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4338
Practice Address - Country:US
Practice Address - Phone:262-741-3200
Practice Address - Fax:262-741-3217
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI392-33363LP0808X, 363L00000X
WI68680-30363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health