Healthcare Provider Details

I. General information

NPI: 1689628703
Provider Name (Legal Business Name): MARY JO P WIEMILLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY JO MATZKE PA

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 N 12TH ST
MILWAUKEE WI
53233-1305
US

IV. Provider business mailing address

945 N 12TH ST
MILWAUKEE WI
53233-1305
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-7880
  • Fax:
Mailing address:
  • Phone: 414-219-7880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1621
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: