Provider Demographics
NPI:1760746424
Name:SALISZ, MOLLIE MAE WITTLIN (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:MAE WITTLIN
Last Name:SALISZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:MAE
Other - Last Name:WITTLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:N79W16331 LONGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-7332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-298-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2934-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant