Provider Demographics
NPI:1659904100
Name:KOSHALEK, RACHEL ROSE
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ROSE
Last Name:KOSHALEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:
Other - Last Name:GRISCHOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2817 NEW PINERY RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9240
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9240
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5120-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant