MEDICARE: MRS. HEATHER RIESSLAND ALLEN P.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	7262-23	WI

General Provider Information

NPI Number	:	1780675603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HEATHER RIESSLAND ALLEN P.A

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	920-663-9008
Fax Number	:	920-684-1439

Provider Business Practice Location Address
First Line	:	2617 DEVELOPMENT DR
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-4240
Country	:	US
Telephone Number	:	920-336-8197
Fax Number	:	920-336-8801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/27/2023

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