Healthcare Provider Details

I. General information

NPI: 1982128112
Provider Name (Legal Business Name): JELENA RADINOVIC PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12203 CORPORATE PKWY
MEQUON WI
53092-3388
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-387-8200
  • Fax:
Mailing address:
  • Phone: 262-387-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4068-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: