Healthcare Provider Details

I. General information

NPI: 1487966305
Provider Name (Legal Business Name): BRENT T VISSAT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 75TH ST
KENOSHA WI
53142-7884
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 262-948-5600
  • Fax: 262-948-5735
Mailing address:
  • Phone: 262-948-5600
  • Fax: 262-948-5735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2576-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: