Provider Demographics
NPI:1164874335
Name:ZOLTAK, ALLISON (PA-C)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:ZOLTAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:
Other - Last Name:LEVRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:717 W MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2432
Mailing Address - Country:US
Mailing Address - Phone:262-542-9100
Mailing Address - Fax:
Practice Address - Street 1:717 W MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2432
Practice Address - Country:US
Practice Address - Phone:262-542-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant