Provider Demographics
NPI:1366137333
Name:MACHURICK, MICHAELA (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:MACHURICK
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-3105
Mailing Address - Country:US
Mailing Address - Phone:920-809-8696
Mailing Address - Fax:
Practice Address - Street 1:5045 W GRANDE MARKET DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8517
Practice Address - Country:US
Practice Address - Phone:920-886-9380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13685-33363L00000X
WI13685208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100239012Medicaid