Provider Demographics
NPI:1710972096
Name:MLSNA, JACQUELINE S (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:MLSNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N MAYFAIR RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1409
Mailing Address - Country:US
Mailing Address - Phone:414-257-2525
Mailing Address - Fax:414-257-1772
Practice Address - Street 1:2500 N MAYFAIR RD
Practice Address - Street 2:SUITE 500
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1409
Practice Address - Country:US
Practice Address - Phone:414-257-2525
Practice Address - Fax:414-257-1772
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29485207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31831600Medicaid
F31137Medicare UPIN
WI31831600Medicaid