Provider Demographics
NPI:1093291494
Name:MAYER, MADELINE M (PA-C)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:M
Last Name:MAYER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:M
Other - Last Name:VICKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:975 PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9201
Mailing Address - Country:US
Mailing Address - Phone:262-329-1000
Mailing Address - Fax:
Practice Address - Street 1:975 PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9201
Practice Address - Country:US
Practice Address - Phone:262-329-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4438-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10008024Medicaid