Provider Demographics
NPI:1114962230
Name:WOLLMER, KELI R (PA)
Entity Type:Individual
Prefix:
First Name:KELI
Middle Name:R
Last Name:WOLLMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELI
Other - Middle Name:R
Other - Last Name:WIRTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:545 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-2237
Mailing Address - Country:US
Mailing Address - Phone:414-288-7184
Mailing Address - Fax:414-288-5681
Practice Address - Street 1:545 N 15TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2237
Practice Address - Country:US
Practice Address - Phone:414-288-7184
Practice Address - Fax:414-288-5681
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI814-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42966500Medicaid
WI42966500Medicaid