Provider Demographics
NPI:1679720312
Name:PEREZ, SUSAN J (PA- C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PA- C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:REID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 W RIVER WOODS PKWY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1060
Mailing Address - Country:US
Mailing Address - Phone:414-465-3091
Mailing Address - Fax:414-465-4842
Practice Address - Street 1:1244 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1987
Practice Address - Country:US
Practice Address - Phone:262-687-2273
Practice Address - Fax:262-687-2014
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2295023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679720312Medicaid