Provider Demographics
NPI:1174524615
Name:WOLF, LAURIE LEE (MD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:LEE
Last Name:WOLF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 N 17TH AVE
Mailing Address - Street 2:SUITE A1
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4200
Mailing Address - Country:US
Mailing Address - Phone:715-298-5783
Mailing Address - Fax:715-298-5784
Practice Address - Street 1:510 N 17TH AVE
Practice Address - Street 2:SUITE A1
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4200
Practice Address - Country:US
Practice Address - Phone:715-298-5783
Practice Address - Fax:715-298-5784
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30639208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31530200Medicaid
WIE12538Medicare UPIN
WI31530200Medicaid
E12538Medicare UPIN
000139151Medicare PIN