Provider Demographics
NPI:1578192423
Name:ETRHEIM, CHARISSA
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:ETRHEIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 DRYDEN DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-3015
Mailing Address - Country:US
Mailing Address - Phone:608-241-9020
Mailing Address - Fax:608-274-0310
Practice Address - Street 1:3209 DRYDEN DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3015
Practice Address - Country:US
Practice Address - Phone:608-241-9020
Practice Address - Fax:608-274-0310
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8653-851207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty