Healthcare Provider Details

I. General information

NPI: 1407481120
Provider Name (Legal Business Name): ALYSSA J SCHWANDA PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALYSSA J FOSSEN

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9576 HIGHWAY 70
MINOCQUA WI
54548-9067
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 715-358-1708
  • Fax: 715-358-1180
Mailing address:
  • Phone: 715-387-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5186
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: