Healthcare Provider Details

I. General information

NPI: 1063408334
Provider Name (Legal Business Name): VASAVI KUMAR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VASAVI REDDY PA

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST STE 209
WAUKESHA WI
53188
US

IV. Provider business mailing address

1111 DELAFIELD ST STE 209
WAUKESHA WI
53188-3403
US

V. Phone/Fax

Practice location:
  • Phone: 262-542-0444
  • Fax: 262-542-8214
Mailing address:
  • Phone: 262-542-0444
  • Fax: 262-542-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1000-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: