Healthcare Provider Details

I. General information

NPI: 1174510457
Provider Name (Legal Business Name): PENNY A WESSON MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N34W28453 TAYLORS WOODS RD
PEWAUKEE WI
53072-3365
US

IV. Provider business mailing address

N34W28453 TAYLORS WOODS RD
PEWAUKEE WI
53072-3365
US

V. Phone/Fax

Practice location:
  • Phone: 262-691-3430
  • Fax:
Mailing address:
  • Phone: 262-691-3430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number46894020
License Number StateWI

VIII. Authorized Official

Name: DR. PENNY ANN WESSON
Title or Position: OWNER
Credential: MD
Phone: 262-691-3430