Provider Demographics
NPI:1275830028
Name:WINDAU, MYRRA JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MYRRA
Middle Name:JEAN
Last Name:WINDAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DIVISION OF ENDOCRINOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6550
Mailing Address - Fax:414-805-6565
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DIVISION OF ENDOCRINOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6550
Practice Address - Fax:414-805-6565
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2714-23363A00000X
WAPA60180632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275830028Medicaid
WI2714-23OtherWISCONSIN STATE PHYSICIAN ASSISTANT LICENSE
WAPA60180632OtherWASHINGTON STATE PHYSICIAN ASSISTANT LICENSE
1092932OtherNCCPA CERTIFICATION
WI68086 0840Medicare PIN
WI1275830028Medicaid