Healthcare Provider Details

I. General information

NPI: 1053542704
Provider Name (Legal Business Name): NESZTA WAHMHOFF PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4122 E TOWNE BLVD
MADISON WI
53704-3732
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-242-6855
  • Fax: 608-242-6848
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2464
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: