Provider Demographics
NPI:1467658195
Name:SOLOLA, MARIE CHRYSTAL (PAC)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:CHRYSTAL
Last Name:SOLOLA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:M.
Other - Middle Name:CHRYSTAL
Other - Last Name:SOLOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:10400 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7884
Mailing Address - Country:US
Mailing Address - Phone:262-948-5600
Mailing Address - Fax:
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-948-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85000396363A00000X
WI4577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100084078Medicaid