Provider Demographics
NPI:1942763024
Name:PREBBLE, ELISA TRIMARCO (MD)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:TRIMARCO
Last Name:PREBBLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3228
Mailing Address - Country:US
Mailing Address - Phone:414-567-5400
Mailing Address - Fax:
Practice Address - Street 1:1432 W FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3228
Practice Address - Country:US
Practice Address - Phone:414-567-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-07
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI77260208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1942763024Medicaid