Healthcare Provider Details

I. General information

NPI: 1619233772
Provider Name (Legal Business Name): TASHA ALEXIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 05/05/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 N. 12TH STREET
MILWAUKEE WI
53233-1305
US

IV. Provider business mailing address

8905 W. WATERFORD SQ. N.
GREENFIELD WI
53228-2261
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-5725
  • Fax:
Mailing address:
  • Phone: 718-614-7273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: