Provider Demographics
NPI:1154079721
Name:GEISLER, GRANT SCOTT
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:SCOTT
Last Name:GEISLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16650 W BLUEMOUND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5959
Mailing Address - Country:US
Mailing Address - Phone:262-827-9200
Mailing Address - Fax:
Practice Address - Street 1:16650 W BLUEMOUND RD STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5959
Practice Address - Country:US
Practice Address - Phone:262-827-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5894-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty