Healthcare Provider Details

I. General information

NPI: 1841746989
Provider Name (Legal Business Name): ELISSA KOWALESKI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10610 N PORT WASHINGTON RD
MEQUON WI
53092-5013
US

IV. Provider business mailing address

10001 W INNOVATION DR STE 200
WAUWATOSA WI
53226-4851
US

V. Phone/Fax

Practice location:
  • Phone: 414-771-6780
  • Fax: 414-238-2424
Mailing address:
  • Phone: 888-938-3838
  • Fax: 888-919-1083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3793 - 23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: