Healthcare Provider Details

I. General information

NPI: 1265588172
Provider Name (Legal Business Name): WAUKESHA PEDIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST SUITE 115
WAUKESHA WI
53188-3417
US

IV. Provider business mailing address

1111 DELAFIELD ST SUITE 115
WAUKESHA WI
53188-3417
US

V. Phone/Fax

Practice location:
  • Phone: 262-542-2536
  • Fax: 262-542-2791
Mailing address:
  • Phone: 262-542-2536
  • Fax: 262-542-2791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDA J JENSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 262-542-2536