Provider Demographics
NPI:1205813334
Name:WELCH, CORINA G (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CORINA
Middle Name:G
Last Name:WELCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:CORINA
Other - Middle Name:D
Other - Last Name:GRETCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:19475 W NORTH AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4199
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1575 N RIVERCENTER DR
Practice Address - Street 2:SUITE 160
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3978
Practice Address - Country:US
Practice Address - Phone:414-274-7220
Practice Address - Fax:414-274-7227
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1397-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41929500Medicaid
WIP00941521OtherRR MEDICARE
WI41929500Medicaid
WI01994-0376Medicare PIN
WI46236-0377Medicare PIN