Provider Demographics
NPI:1265034169
Name:HUMISTON, MEREDITH KATHERINE (CAA)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:KATHERINE
Last Name:HUMISTON
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S KINNICKINNIC AVE APT 425
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-1324
Mailing Address - Country:US
Mailing Address - Phone:414-322-6607
Mailing Address - Fax:765-751-2757
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-15
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant