Individual
MARK FREDERICK WOLLUM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.T.
Contact information
Practice address
1235 S 24TH ST, MANITOWOC, WI 54220-5516
(920) 682-8254
Mailing address
108 SMITH DR, BEAVER DAM, WI 53916-2746
(920) 887-8748
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
3568-024
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
40311800
—
WI
Enumeration date
05/06/2007
Last updated
07/08/2007
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