Healthcare Provider Details

I. General information

NPI: 1841751898
Provider Name (Legal Business Name): ELIZABETH PETESCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2019
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 PINE RIDGE BLVD STE 211
WAUSAU WI
54401-4123
US

IV. Provider business mailing address

UW HOSPITALS AND CLINICS 600 HIGHLAND AVE
MADISON WI
53792-0001
US

V. Phone/Fax

Practice location:
  • Phone: 715-845-5505
  • Fax: 715-848-2884
Mailing address:
  • Phone: 608-263-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number75288-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: