Healthcare Provider Details

I. General information

NPI: 1689443137
Provider Name (Legal Business Name): REBECCA MARIA PATEL CAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA MARIA WIRTH

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W180N8085 TOWN HALL RD
MENOMONEE FALLS WI
53051-3518
US

IV. Provider business mailing address

W180N8085 TOWN HALL RD
MENOMONEE FALLS WI
53051-3518
US

V. Phone/Fax

Practice location:
  • Phone: 262-257-5100
  • Fax: 262-518-5052
Mailing address:
  • Phone: 262-257-5100
  • Fax: 262-518-5052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number545-17
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: