Healthcare Provider Details

I. General information

NPI: 1194792895
Provider Name (Legal Business Name): PAUL PRUESSING PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KK RIVER PKWY SUITE 1030
MILWAUKEE WI
53215-3669
US

IV. Provider business mailing address

3033 S 27TH ST SUITE 202
MILWAUKEE WI
53215-3600
US

V. Phone/Fax

Practice location:
  • Phone: 414-908-6500
  • Fax: 414-385-2980
Mailing address:
  • Phone: 414-908-6601
  • Fax: 414-385-2980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number357-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: