Provider Demographics
NPI:1215542683
Name:FLANDERS, CARY WILKINS
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:WILKINS
Last Name:FLANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2801
Mailing Address - Country:US
Mailing Address - Phone:716-307-6407
Mailing Address - Fax:
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-13
Last Update Date:2021-11-29
Deactivation Date:2020-09-13
Deactivation Code:
Reactivation Date:2021-11-18
Provider Licenses
StateLicense IDTaxonomies
WI5602-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant