Provider Demographics
NPI:1497940233
Name:HASSE-RUPP, BRENDA J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:J
Last Name:HASSE-RUPP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:J
Other - Last Name:HASSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC DERMATOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-805-3666
Mailing Address - Fax:414-266-3315
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC DERMATOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-805-3666
Practice Address - Fax:414-266-3315
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2182-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1497940233Medicaid
WI1497940233Medicaid