Healthcare Provider Details

I. General information

NPI: 1215924527
Provider Name (Legal Business Name): GREGORY JACKSON AYCOCK CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE
MADISON WI
53792-0001
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS40328
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberPENDING
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number618
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17641
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number75000176A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: