Healthcare Provider Details

I. General information

NPI: 1194004325
Provider Name (Legal Business Name): PATRICIA A. EDER SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 75TH ST
KENOSHA WI
53142-7884
US

IV. Provider business mailing address

3305 86TH ST
KENOSHA WI
53142-2573
US

V. Phone/Fax

Practice location:
  • Phone: 262-948-6866
  • Fax:
Mailing address:
  • Phone: 262-942-7003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number11-177
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: