Provider Demographics
NPI:1063673457
Name:BROCHHAUSEN, CHRISTY M (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:M
Last Name:BROCHHAUSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:M
Other - Last Name:FLAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:N84W16889 MENOMONEE AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2810
Practice Address - Country:US
Practice Address - Phone:262-251-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42003000Medicaid
WIP00941427OtherRR MEDICARE
WI46236-0321Medicare PIN
WI01994-0322Medicare PIN