Provider Demographics
NPI:1356442081
Name:DEPA, MICHELLE ANN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:DEPA
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 1:4025 N 92ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222
Mailing Address - Country:US
Mailing Address - Phone:414-358-5431
Mailing Address - Fax:414-358-5421
Practice Address - Street 1:8901 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2409
Practice Address - Country:US
Practice Address - Phone:414-328-7200
Practice Address - Fax:414-328-8158
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127713-030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI61045OtherDEAN HEALTH INSURANCE
WI543400543Medicare PIN
WI741501757Medicare PIN