Healthcare Provider Details

I. General information

NPI: 1912149170
Provider Name (Legal Business Name): KRISTEN ANN KLEMENT TASSONE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN ANN HUDAK M.D.

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 N MAYFAIR RD
WAUWATOSA WI
53226-3462
US

IV. Provider business mailing address

1155 N MAYFAIR RD
WAUWATOSA WI
53226-3462
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-4263
  • Fax: 414-955-6286
Mailing address:
  • Phone: 414-955-4263
  • Fax: 414-955-6286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number54773-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: