Healthcare Provider Details

I. General information

NPI: 1952872376
Provider Name (Legal Business Name): AMANDA JANCZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
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: 414-805-5800
  • Fax: 414-805-8097
Mailing address:
  • Phone: 414-805-5800
  • Fax: 414-805-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4435-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: