Healthcare Provider Details

I. General information

NPI: 1578827960
Provider Name (Legal Business Name): ELONA COMO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13133 N PORT WASHINGTON RD SUITE 104
MEQUON WI
53097-2419
US

IV. Provider business mailing address

788 N JEFFERSON ST SUITE 300
MILWAUKEE WI
53202-3718
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-5044
  • Fax: 262-243-2510
Mailing address:
  • Phone: 414-272-8950
  • Fax: 414-225-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2970
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: