Healthcare Provider Details

I. General information

NPI: 1356524870
Provider Name (Legal Business Name): SHAE M WHEELER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAE M ELLEFSON/BLAKLEY

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S ONEIDA ST
APPLETON WI
54915-1305
US

IV. Provider business mailing address

111 E WISCONSIN AVE SUITE 2000
MILWAUKEE WI
53202-4815
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6720
  • Fax: 414-290-6755
Mailing address:
  • Phone: 414-290-6720
  • Fax: 414-290-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number664-039
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2741-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: