Provider Demographics
NPI:1154636447
Name:GLEISNER, ANGELA K (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:K
Last Name:GLEISNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:K
Other - Last Name:GRELK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8400 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3735
Practice Address - Country:US
Practice Address - Phone:262-884-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2583-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100010915Medicaid
WI2853-23OtherWI LICENSE