Healthcare Provider Details

I. General information

NPI: 1528887320
Provider Name (Legal Business Name): JOSEPH JAMES THIRY MSPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
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: 414-777-7700
  • Fax:
Mailing address:
  • Phone: 414-805-0505
  • Fax: 414-955-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8147-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: