Provider Demographics
NPI:1235753922
Name:RICHARDS, ELIZABETH GRACE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:GRACE
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:GRACE
Other - Last Name:GARNCARZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-6450
Mailing Address - Fax:414-955-0082
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-6450
Practice Address - Fax:414-955-0082
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5229-23363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1235753922Medicaid