Healthcare Provider Details

I. General information

NPI: 1548667231
Provider Name (Legal Business Name): TANYA WATRY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WISCONSIN AMERICAN DR
FOND DU LAC WI
54937
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-907-7000
  • Fax:
Mailing address:
  • Phone: 920-907-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3424
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: