=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215261987
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRASHANTI SHIVARAM P.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2009
-----------------------------------------------------
Last Update Date | 09/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7400 W RAWSON AVE SUITE 225
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53132-8278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-425-8232
-----------------------------------------------------
Fax | 414-425-8267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7400 W RAWSON AVE SUITE 225
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53132-8278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-425-8232
-----------------------------------------------------
Fax | 414-425-8267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 2467-023
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 2467-023
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------