Provider Demographics
NPI:1588003354
Name:URBAITIS, JESSEE TAYLOR (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JESSEE
Middle Name:TAYLOR
Last Name:URBAITIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSEE
Other - Middle Name:TAYLOR
Other - Last Name:PORTER
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:414-805-4600
Mailing Address - Fax:414-805-2934
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:414-805-4600
Practice Address - Fax:414-805-2934
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005796363AM0700X, 363AM0700X
WI4361-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4361-23OtherWI LICENSE
WI1588003354Medicaid