Provider Demographics
NPI:1073533097
Name:THORESEN, MARILEE (PA)
Entity Type:Individual
Prefix:
First Name:MARILEE
Middle Name:
Last Name:THORESEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 JOHN Q HAMMONS DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1941
Mailing Address - Country:US
Mailing Address - Phone:608-251-4156
Mailing Address - Fax:608-257-3842
Practice Address - Street 1:5249 E TERRACE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-8339
Practice Address - Country:US
Practice Address - Phone:608-222-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42908200Medicaid
WIS69128Medicare UPIN