Provider Demographics
NPI:1639726656
Name:ELLESEG, ASHLEY V (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:V
Last Name:ELLESEG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:V
Other - Last Name:GAVIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N84W16889 MENOMONEE AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2810
Practice Address - Country:US
Practice Address - Phone:262-251-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1173669363A00000X
363A00000X
WI5081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100138733Medicaid