Provider Demographics
NPI:1922342591
Name:SPYCHALLA, LAURA L (PAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:SPYCHALLA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:PAQUET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC NEUROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-3464
Mailing Address - Fax:414-266-3466
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC NEUROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-3464
Practice Address - Fax:414-266-3466
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1922342591Medicaid
WI1922342591Medicaid