Provider Demographics
NPI:1639787104
Name:HETZEL, EMILY THEREAS (PA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:THEREAS
Last Name:HETZEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:THEREAS
Other - Last Name:POWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:725 AMERICAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5031
Mailing Address - Country:US
Mailing Address - Phone:262-928-8800
Mailing Address - Fax:
Practice Address - Street 1:725 AMERICAN AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:262-928-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI5243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program