Healthcare Provider Details

I. General information

NPI: 1235753922
Provider Name (Legal Business Name): ELIZABETH GRACE RICHARDS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH GRACE GARNCARZ PA-C

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-6450
  • Fax: 414-955-0082
Mailing address:
  • Phone: 414-955-6450
  • Fax: 414-955-0082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5229-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: