Individual
JUAN SEBASTIAN PRECIADO-RIESTRA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
400 S TOWNLINE RD, WAUTOMA, WI 54982-6922
(920) 787-4737
Mailing address
933 BUFFALO RIDGE LN, WAUPACA, WI 54981-8192
(715) 252-2899
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
46438-020
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
34313600
—
WI
01
—
46438
WI STATE LIC
WI
01
—
521823
MEDICARE PART A - CLINIC
WI
01
—
521824
MEDICARE A MOBIL UNIT
WI
Enumeration date
06/08/2005
Last updated
04/29/2016
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