Healthcare Provider Details

I. General information

NPI: 1457011249
Provider Name (Legal Business Name): MARIA GRACIA GMEHLIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA GRACIA ROJAS INFANTAS PA-C

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13133 N PORT WASHINGTON RD STE G16
MEQUON WI
53097-2423
US

IV. Provider business mailing address

13111 N PORT WASHINGTON RD
MEQUON WI
53097-2416
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-2500
  • Fax:
Mailing address:
  • Phone: 262-243-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5578-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: