Provider Demographics
NPI:1871577577
Name:LASECKI, CYNTHIA B (MD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:B
Last Name:LASECKI
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1800 LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9108
Practice Address - Country:US
Practice Address - Phone:920-983-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38248207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38248OtherLICENSE
WIG34925Medicare UPIN
WI38248OtherLICENSE
WI075100141Medicare Oscar/Certification
WI080089002Medicare Oscar/Certification
WI075100141Medicare Oscar/Certification