Provider Demographics
NPI:1821050105
Name:GERCZAK, CORINA L (PA)
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:L
Last Name:GERCZAK
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:1800 LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115
Practice Address - Country:US
Practice Address - Phone:920-983-3220
Practice Address - Fax:920-983-3226
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1960-023OtherLICENSE
WI073100045Medicare Oscar/Certification
WI000207845Medicare Oscar/Certification
Q68330Medicare UPIN
WIK400157168Medicare Oscar/Certification
WIK400157172Medicare Oscar/Certification
WI1960-023OtherLICENSE
Q68330Medicare UPIN
WI000012Medicare Oscar/Certification
WI000021Medicare Oscar/Certification
WI000040Medicare Oscar/Certification
000025Medicare Oscar/Certification
WI000073Medicare Oscar/Certification
WI000179Medicare Oscar/Certification
WI000189Medicare Oscar/Certification
WI1960-023OtherLICENSE
WI002150279Medicare Oscar/Certification
WI000029Medicare Oscar/Certification
WI000450Medicare Oscar/Certification