Provider Demographics
NPI:1790870079
Name:WACKER, BETSY J (PAC)
Entity Type:Individual
Prefix:MRS
First Name:BETSY
Middle Name:J
Last Name:WACKER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 PINE ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54768-1297
Mailing Address - Country:US
Mailing Address - Phone:715-644-5530
Mailing Address - Fax:715-644-6223
Practice Address - Street 1:1120 PINE ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:WI
Practice Address - Zip Code:54768-1297
Practice Address - Country:US
Practice Address - Phone:715-644-5530
Practice Address - Fax:715-644-6223
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42989100Medicaid
WI42989100Medicaid
S74262Medicare UPIN