Provider Demographics
NPI:1003392770
Name:ANAGNOUSTOPOLOUS, DEMI ELISABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:DEMI
Middle Name:ELISABETH
Last Name:ANAGNOUSTOPOLOUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W180N8085 TOWN HALL RD
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3518
Mailing Address - Country:US
Mailing Address - Phone:262-251-1000
Mailing Address - Fax:262-518-5052
Practice Address - Street 1:W180N8085 TOWN HALL RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3518
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4529-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003392770Medicaid