Provider Demographics
NPI:1821002049
Name:REISEN-GARVEY, MICHELLE L (PA)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:L
Last Name:REISEN-GARVEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53530-1225
Mailing Address - Country:US
Mailing Address - Phone:608-776-4497
Mailing Address - Fax:608-776-2837
Practice Address - Street 1:731 CLAY ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53530-1225
Practice Address - Country:US
Practice Address - Phone:608-776-4497
Practice Address - Fax:608-776-2837
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1251-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400186776Medicare PIN