Healthcare Provider Details

I. General information

NPI: 1720909476
Provider Name (Legal Business Name): ALLISON MARIE BULLOCK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 N 12TH ST
MILWAUKEE WI
53233-1305
US

IV. Provider business mailing address

740 W WISCONSIN AVE APT 202
MILWAUKEE WI
53233-2409
US

V. Phone/Fax

Practice location:
  • Phone: 205-928-6079
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: