1205813334 NPI number — MRS. CORINA G. WELCH PA-C

Table of content: MRS. CORINA G. WELCH PA-C (NPI 1205813334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205813334 NPI number — MRS. CORINA G. WELCH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELCH
Provider First Name:
CORINA
Provider Middle Name:
G.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRETCH
Provider Other First Name:
CORINA
Provider Other Middle Name:
D.
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205813334
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19475 W NORTH AVE
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53045-4199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-352-3100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1575 N RIVERCENTER DR
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53212-3978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-274-7220
Provider Business Practice Location Address Fax Number:
414-274-7227
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1397-023 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41929500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00941521 . This is a "RR MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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