MEDICARE: TAMYRA N TRICE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	2023-023	WI
2	363A00000X	Physician Assistant	2023-023	WI

General Provider Information

NPI Number	:	1740291483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMYRA N TRICE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 80257
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-8004
Country	:	US
Telephone Number	:	414-935-8000
Fax Number	:	414-344-3396

Provider Business Practice Location Address
First Line	:	1452 N 7TH ST FL 2
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205
Country	:	US
Telephone Number	:	414-935-8000
Fax Number	:	414-287-0907

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	05/15/2020

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