Provider Demographics
NPI:1962458158
Name:THEISEN, MARIA L (PA)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:L
Last Name:THEISEN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC PLASTIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2876
Mailing Address - Fax:414-266-2957
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC PLASTIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2876
Practice Address - Fax:414-266-2957
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1200363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962458158Medicaid
008000261FOtherHUMANA
S84047Medicare UPIN
WI1962458158Medicaid
WI736012009Medicare PIN