Provider Demographics
NPI:1366446841
Name:MOERICKE, DOUGLAS B (PA)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:B
Last Name:MOERICKE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18601 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:WI
Mailing Address - Zip Code:54773-8605
Mailing Address - Country:US
Mailing Address - Phone:715-538-1712
Mailing Address - Fax:
Practice Address - Street 1:18601 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:WI
Practice Address - Zip Code:54773-8605
Practice Address - Country:US
Practice Address - Phone:715-538-4361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI492363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42940400Medicaid
WI42940400Medicaid
WI0789Medicare ID - Type Unspecified