Provider Demographics
NPI:1508455247
Name:FAWCETT, AUDREY BROOKE (PA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:BROOKE
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:520 PARK RIDGE CT APT H
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-5608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4805 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7401
Practice Address - Country:US
Practice Address - Phone:262-798-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-17
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI7469-23363A00000X
IN10003168A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant