Healthcare Provider Details

I. General information

NPI: 1184722001
Provider Name (Legal Business Name): MARCELLE BULLARD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14555 W NATIONAL AVE
NEW BERLIN WI
53151-4494
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 262-827-3636
  • Fax:
Mailing address:
  • Phone: 143-892-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085-002401
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3485-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: