Provider Demographics
NPI:1205543899
Name:WAVRA, MICHELLE (APNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WAVRA
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 WINNEBAGO DR
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5002
Mailing Address - Country:US
Mailing Address - Phone:262-613-5357
Mailing Address - Fax:
Practice Address - Street 1:10625 W NORTH AVE STE 101B
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2315
Practice Address - Country:US
Practice Address - Phone:414-877-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13272-33207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine