ROECKER, DEANNA L (PA-C)

Provider Demographics

• NPI: 1851336408
• Name: ROECKER, DEANNA L (PA-C)
• Entity Type: Individual
• First Name: DEANNA
• Middle Name: L
• Last Name: ROECKER
• Gender: F
• Credentials: PA-C
• Other - First Name: DEANNA
• Other - Middle Name: L
• Other - Last Name: WILLING
• Other - Last Name Type: Former Name
• Other - Credentials: PA-C
• Mailing Address - Street 1: 111 E WISCONSIN AVE
• Mailing Address - Street 2: SUITE 2000
• Mailing Address - City: MILWAUKEE
• Mailing Address - State: WI
• Mailing Address - Zip Code: 53202-4815
• Mailing Address - Country: US
• Mailing Address - Phone: 414-290-6720
• Mailing Address - Fax: 414-290-6755
• Practice Address - Street 1: 111 E WISCONSIN AVE
• Practice Address - Street 2: SUITE 2000
• Practice Address - City: MILWAUKEE
• Practice Address - State: WI
• Practice Address - Zip Code: 53202-4815
• Practice Address - Country: US
• Practice Address - Phone: 414-290-6720
• Practice Address - Fax: 414-290-6755
• Is Sole Proprietor?: No
• Enumeration Date: 2006-06-18
• Last Update Date: 2008-05-19

Provider Licenses

State	License ID	Taxonomies
IL	085-002184	363A00000X
WI	610-023	363A00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WI	42963200	Medicaid
WI	970008498	Other	MEDICARE RAILROAD
WI	970008514	Other	MEDICARE RAILROAD
WI	0049-32350	Medicare ID - Type Unspecified
WI	0053-32280	Medicare ID - Type Unspecified
	S33138	Medicare UPIN
WI	0058-01400	Medicare ID - Type Unspecified
IL	K08705	Medicare ID - Type Unspecified
WI	0014-01240	Medicare ID - Type Unspecified
WI	970008514	Other	MEDICARE RAILROAD