MEDICARE: MR. DOUGLAS JEROME WOIDA MS PAS, 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	1865-23	WI
2	363A00000X	Physician Assistant	1865	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790823045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS JEROME WOIDA MS PAS, PA-C

Provider Business Mailing Address
First Line	:	1214 ORIOLE DR
Second Line	:
City	:	OCONOMOWOC
State	:	WI
Zip	:	53066-2373
Country	:	US
Telephone Number	:	414-759-4111
Fax Number	:

Provider Business Practice Location Address
First Line	:	8500 W CAPITOL DR STE 100
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-1869
Country	:	US
Telephone Number	:	414-431-5004
Fax Number	:	414-431-2959

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

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	01/18/2019

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