Provider Demographics
NPI:1629016571
Name:MARCINIAK, DEBRA (PA)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:
Last Name:MARCINIAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENTN OF EMERGENCY MEDICINE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6450
Mailing Address - Fax:414-805-6464
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENTN OF EMERGENCY MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6450
Practice Address - Fax:414-805-6464
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629016571Medicaid
003000261HOtherHUMANA
003000261HOtherHUMANA
0006773601Medicare ID - Type Unspecified