Provider Demographics
NPI:1033589635
Name:AGARWAL, SUPATRA A (AA)
Entity Type:Individual
Prefix:
First Name:SUPATRA
Middle Name:A
Last Name:AGARWAL
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:SUPATRA
Other - Middle Name:A
Other - Last Name:CHANTACHOTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:9200 W WISCONSIN AVENUE
Mailing Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8700
Mailing Address - Fax:414-259-1522
Practice Address - Street 1:9200 W WISCONSIN AVENUE
Practice Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8700
Practice Address - Fax:414-259-1522
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI95367H00000X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015797000Medicaid
FL015797000Medicaid