Provider Demographics
NPI:1679675557
Name:DERSE-HAYES, MARY J (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:DERSE-HAYES
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 300/ATTN. KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-225-2929
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE 302
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7104
Practice Address - Fax:414-298-7117
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2016-11-09
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Provider Licenses
StateLicense IDTaxonomies
WI2046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679675557Medicaid
WI1679675557Medicaid
736450050Medicare PIN