Provider Demographics
NPI:1649759689
Name:TELLIER, MARY (PAS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TELLIER
Suffix:
Gender:F
Credentials:PAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-325-5244
Mailing Address - Fax:414-421-3772
Practice Address - Street 1:6901 W EDGERTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4420
Practice Address - Country:US
Practice Address - Phone:414-325-5244
Practice Address - Fax:414-421-3772
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5920363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100085581Medicaid