Provider Demographics
NPI:1629364815
Name:RICCHIO, ALYSSA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:M
Last Name:RICCHIO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:M
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10400 75TH ST STE 700
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7884
Mailing Address - Country:US
Mailing Address - Phone:262-948-6618
Mailing Address - Fax:
Practice Address - Street 1:10400 75TH ST STE 700
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7884
Practice Address - Country:US
Practice Address - Phone:262-948-6618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-26
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2769-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629364815Medicaid