Provider Demographics
NPI:1467705756
Name:NAULT, ALLYSE M (PA-C)
Entity Type:Individual
Prefix:
First Name:ALLYSE
Middle Name:M
Last Name:NAULT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALLYSE
Other - Middle Name:M
Other - Last Name:MERVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-1700
Mailing Address - Fax:414-955-0072
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-1700
Practice Address - Fax:414-955-0072
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3047-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467705756Medicaid