Provider Demographics
NPI:1326650698
Name:MENEFEE, DYLAN HENRY (PA-C)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:HENRY
Last Name:MENEFEE
Suffix:
Gender:M
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 1:1510 N MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-2030
Mailing Address - Country:US
Mailing Address - Phone:414-659-0211
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:414-659-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5189-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant