Provider Demographics
NPI:1093140816
Name:BLUM, ALYSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSA
Middle Name:
Last Name:BLUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALYSA
Other - Middle Name:
Other - Last Name:MCGOVERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:615 W MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2462
Mailing Address - Country:US
Mailing Address - Phone:262-896-8429
Mailing Address - Fax:262-896-8521
Practice Address - Street 1:615 W MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2462
Practice Address - Country:US
Practice Address - Phone:262-896-8420
Practice Address - Fax:262-896-8521
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3150-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIMB3031957OtherDEA