Provider Demographics
NPI:1952312746
Name:MORTELL, JAMES A (PA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:A
Last Name:MORTELL
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2600 N MAYFAIR RD
Mailing Address - Street 2:SUITE 901
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1309
Mailing Address - Country:US
Mailing Address - Phone:414-778-4976
Mailing Address - Fax:414-778-3445
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:SUITE 901
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1309
Practice Address - Country:US
Practice Address - Phone:414-778-4976
Practice Address - Fax:414-778-3445
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI258023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42925900Medicaid
WI42925900Medicaid