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General NPI Number Information
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NPI Number | 1184722001
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Entity Type | Individual
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Provider Name | MARCELLE BULLARD PA
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Gender | Female
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 11/29/2021
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Provider Practice Location Address
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Address Line | 14555 W NATIONAL AVE
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City | NEW BERLIN
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State | WI
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Zip | 53151-4494
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Country | US
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Telephone | 262-827-3636
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Fax |
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Provider Business Mailing Address
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Address Line | 3301 W FOREST HOME AVE
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City | MILWAUKEE
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State | WI
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Zip | 53215-2843
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Country | US
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Telephone | 143-892-3774
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 085-002401
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 3485-023
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License Number State | WI
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