Provider Demographics
NPI:1891716593
Name:RISSE, AMANDA S (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:S
Last Name:RISSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:S
Other - Last Name:BUCKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2999 N MAYFAIR RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4306
Mailing Address - Country:US
Mailing Address - Phone:414-479-7000
Mailing Address - Fax:
Practice Address - Street 1:2999 N MAYFAIR RD STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-4306
Practice Address - Country:US
Practice Address - Phone:414-479-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1982-23363A00000X
WI1982-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1071546OtherNCCPA BOARD CERTIFICATION
WI41947600Medicaid
WI462364920Medicare PIN
WI1071546OtherNCCPA BOARD CERTIFICATION
WIQ73077Medicare UPIN
WI000473220Medicare PIN