Provider Demographics
NPI:1679650956
Name:SZAMOCKI, HEATHER A (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:SZAMOCKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:A
Other - Last Name:BAUMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:830 E GREEN BAY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080-2662
Mailing Address - Country:US
Mailing Address - Phone:262-284-7117
Mailing Address - Fax:
Practice Address - Street 1:830 E GREEN BAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080-2662
Practice Address - Country:US
Practice Address - Phone:262-284-7117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42927700Medicaid
WI42927700Medicaid