Provider Demographics
NPI:1942452289
Name:KELCH, ALICIA S (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:S
Last Name:KELCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ALICIA
Other - Middle Name:S
Other - Last Name:VESPIGNANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:16505 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W156N9000 PILGRIM RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051
Practice Address - Country:US
Practice Address - Phone:262-502-8752
Practice Address - Fax:262-502-8756
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2367-23207P00000X
WI236723363AM0700X
PAMA052264363AM0700X
WI2367-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1942452289Medicaid
WI1942452289OtherBLUE SHIELD
WI1942452289Medicaid
WI1942452289OtherBLUE SHIELD