Provider Demographics
NPI:1063472488
Name:RIESCH, JUDITH M (PA)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:RIESCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:M
Other - Last Name:SEUBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:601 N 99 ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-266-9700
Mailing Address - Fax:414-266-9701
Practice Address - Street 1:601 N 99 ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-266-9700
Practice Address - Fax:414-266-9701
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI470023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42931200Medicaid
S66943Medicare UPIN